Suicidal behaviour and psychosocial problems in ...

Soc Psychiat Epidemiol DOI 10.1007/s00127-010-0328-6

ORIGINAL PAPER

Suicidal behaviour and psychosocial problems in veterinary surgeons: a systematic review Belinda Platt • Keith Hawton • Sue Simkin Richard J. Mellanby

•

Received: 24 June 2010 / Accepted: 1 December 2010 Ó Springer-Verlag 2010

Abstract Purpose Rates of suicide are elevated among veterinary surgeons in several countries, yet little is known about contributory factors. We have conducted a systematic review of studies investigating suicidal behaviour and psychosocial problems in veterinary surgeons. Methods A systematic search of the international research literature was performed in May 2008. Data from 52 studies of non-fatal suicidal behaviour, mental health difficulties, stress and burnout, occupational difficulties, and psychological characteristics of veterinary surgeons were extracted by two independent reviewers and analysed. Studies were rated for quality and greater emphasis placed on findings from higher quality studies. Results The majority of studies were of stress and occupational difficulties experienced by veterinary surgeons. Occupational stressors included managerial aspects of the job, long working hours, heavy workload, poor work-life balance, difficult client relations, and performing euthanasia. Few studies investigated suicidal behaviour or mental health difficulties in the profession. Some studies suggested that young and female veterinarians are at greatest risk of negative outcomes such as suicidal thoughts, mental health difficulties, and job dissatisfaction. Conclusions The review highlights the difficulties faced by veterinary surgeons that may contribute to poor mental wellbeing and suicidal behaviour. Future research might B. Platt (&) K. Hawton S. Simkin Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK e-mail: [email protected] R. J. Mellanby Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK

include further examination of the influence of euthanasia on attitudes towards suicide and more direct examination of the impact that occupational risk factors might have on suicidal behaviour. Suggestions about the review’s implications for suicide prevention in this group are also made. Keywords Suicide Veterinarian Systematic review Wellbeing Mental health Occupation

Introduction Internationally around 1,000,000 people die from suicide each year, making it a leading cause of death in both developing countries and the western world [92]. Elevated suicide rates in certain occupational groups have been reported from studies in the UK [16, 53, 64, 83], Australia [2], Denmark [1], France [18], Japan [50], New Zealand [29], Sweden [84], and the USA [15]. Research into the factors associated with suicide in specific populations has been influential in the development of national suicide prevention strategies [22]. Psychological autopsy studies have been used to investigate the reasons why doctors [36], nurses [37], and farmers [41] might be more likely to die by suicide than other members of the general population. Contributory factors are thought to include relatively easy access to the means for suicide, increased prevalence of mental health disorders, occupational stress, professional isolation and reluctance to seek help for problems [36, 37, 41, 80]. Rates of suicide also appear to be significantly elevated in veterinary surgeons in the UK [17, 53, 56, 64, 66, 83], the USA [11, 12, 59, 67, 68, 78], Belgium [61], Norway [46], and Australia [48]. Due to a lack of population denomination data in many of these studies the proportional mortality ratio (PMR) for suicide has often

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been used [72]. However, interpretation of PMR is limited given that it is influenced by other causes of death in the population studied. Research investigating the specific occupational difficulties of veterinary work and the prevalence of mental health problems may be useful in understanding suicidal behaviour in the profession. This is also likely to be important for the development of effective prevention strategies. Easier access to the means for suicide is one of the most commonly cited contributory factors to suicide in the occupational groups at highest risk of suicide. Both farmers [40] and doctors [38] often use suicide methods related to their work and some studies have suggested that self-poisoning and firearms are particularly common methods of suicide in the veterinary profession [11, 12, 48, 53, 68]. However, not all veterinary surgeons use methods obtained at work in their suicidal act and evidence from other occupational groups suggests that the prevalence of mental illness and occupational difficulties may also account for elevated rates of suicide. Psychiatric disorder (usually depression) has been reported in over 80% of cases of suicide in doctors [36] and farmers [41]. Several studies suggest that mental health difficulties may also be common in the veterinary profession [30, 63]. Furthermore, in a study conducted in the USA 87% of veterinarians found their job stressful and 67% demonstrated symptoms of the beginnings of burnout syndrome [25]. Personality traits such as perfectionism are associated with suicidal behaviour [69] and are known to be prominent in the medical profession [10]. The psychological characteristics of those attracted to the veterinary profession are relatively under-researched. We have conducted a systematic review of the international research literature on suicidal behaviour and psychosocial problems in the veterinary profession in order to summarize current knowledge and indicate future research directions. In this report, we focus on studies of non-fatal suicidal behaviour, mental health difficulties, stress and burnout, occupational difficulties, and the psychological characteristics of veterinary surgeons. A preliminary search of the literature suggested that the quality of research in this field varies greatly. Guidelines for the conduct of systematic reviews highlight the importance of assessing study quality in order to maximize the reliability and validity of the review process [77, 87]. Given that no rating scale exists to assess quality in studies of this nature, the authors have developed a quality rating scale based on existing guidelines for systematic reviews of similar areas [77]. We have focused the results and discussion sections of this review on the studies that received the highest quality ratings.

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Methods The systematic review procedure is illustrated in Fig. 1. An electronic search was conducted in May 2008 of the databases MEDLINE (1950–present), EMBASE (1980– present), AMED (1982–present), BNI (1985–present), CINAHL (1982–present), PsycINFO (1806–present), SCOPUS, Web of Science (1945–present), and IBSS (1951–present). The terms ‘wellbeing’, ‘emotion*’, ‘anxiet*’, ‘psycholog*’, ‘mortalit*’, ‘mental illness’, ‘mental health’, ‘stress*’, ‘depress*’, ‘self harm’, ‘suicid*’ were combined with ‘veterinar*’ and ‘vets’ in a free-text search. In addition, the subject headings associated with suicideand veterinary-related terms were searched in order to identify any papers not coded with the appropriate terms by the managers of the electronic reference databases. There were no language restrictions. The references identified through the search were randomly distributed to reviewers 1–4 (KH, SS, RM, LS) who independently screened the reference abstracts according to the three study inclusion criteria: (1) reported on suicide or related issues of wellbeing; (2) in relation to veterinary surgeons or students of veterinary medicine; and (3) reports which were published in a journal or book, were in press or were an unpublished dissertation. Each abstract was also independently screened by reviewer 5 (BP). On occasions when reviewers 1–4 disagreed with reviewer 5, the opinion of a sixth, independent reviewer (LH) was used to determine whether the reference met inclusion criteria or not. In total, 970 references met inclusion criteria and were forwarded for fulltext screening. Full-text screening involved random distribution of each paper to reviewers 1, 2 or 3 in addition to reviewer 5. Papers were categorized according to the following formats, in relation to suicidal behaviour or psychosocial problems: (1) empirical data; (2) theoretical accounts, e.g. a model of suicide; (3) atheoretical accounts, e.g. a personal account of depression; and (4) irrelevant to the review protocol. Full-text screening of the 108 papers published in non-English languages was conducted between a translator and reviewer in collaboration. When there was disagreement about the category to which a paper should be assigned, the respective reviewers discussed their views until a consensus decision could be reached. Additional search methods included handsearching the references of papers that presented empirical data, asking international experts in the field to review the final list of empirical studies, and searching a weekly updated electronic database of injury prevention research literature (http://www.safetylit.org). Any papers identified by these additional methods were randomly allocated to reviewers 1–3 and reviewer 5 for full-text screening.


Electronic search strategy conducted (N=13121) Abstract screening

Both reviewers agreed paper met

Disagreement about whether paper met

Both reviewers agreed paper did not meet abstract

Duplicates

abstract screening criteria (N=488)

abstract screening criteria (N=837)

screening criteria (N=11623)

(N=173)

A sixth reviewer screened abstracts

Abstract screening criteria not met (N=355)

Abstract screening criteria met (N=482)

Full-text screening (N=970)

Paper met full-text screening

Paper met full-text criteria 2:

Paper met full-text criteria 3:

Irrelevant to the

Full-text

Duplicates

criteria 1: empirical data

theoretical issues (N=82)

non-theoretical accounts

review protocol

could not be

identified

(N=153)

(N=625)

retrieved

manually

(N=91)

Additional papers identified from reference lists (N=18)

Papers identified by other means (N=26)

International experts identified extra references (N=2)

Paper met full-text criteria 2, 3 or 4 (N=7+13+8=28)

Paper met full-text

Full-text screening (N=46)

N=34 N=14

criteria 1 (N=12) Data extraction (N=103)

Paper published after inclusion date (N=18)

70 papers on non-fatal suicidal behaviour or wellbeing in veterinary surgeons (N=47), students (N=22), or both (N=1) and

Duplicates or unable to locate

19 papers on the prevalence of suicide in veterinary surgeons

(N=2)

Fig. 1 Flow chart of the systematic review process

A data extraction form was developed specifically for survey studies of non-fatal suicidal behaviour and psychosocial problems. The form contained the following sections: (a) type of survey that was conducted (including the issues addressed), (b) description of the recruitment methods, (c) demographic information about the sample, (d) data on stress or mental health (including prevalence of the problem, the causes/contributory factors, treatment/ support, and comparisons with other populations), (e) data on non-fatal suicidal behaviour, (f) any data on psychosocial problems, g) evaluative information such as limitations of the study and areas the authors identified for future research. Data extraction was performed by reviewer 5 and the results randomly distributed to reviewers 1–3 to ensure accuracy and completion. Data from the five papers not written in English (two French and three Dutch) were extracted in a collaborative effort between a native speaker of the respective language and reviewer 5. The overall quality of the survey studies was assessed using a tool developed by the authors (Table 1). The scale contained 12 items which were coded yes/no, resulting in a maximum score of 12. The scores obtained using this measure were used by the authors to distinguish studies of low quality (scores 0–4), moderate quality (scores 5–8) and high quality (scores 9–12).

Results Results of the search and inter-reviewer reliability The initial electronic search strategy identified 13,121 references, with 12,948 unique references remaining once duplicates had been removed. At the abstract screening level, both reviewers agreed on whether 12,111 (93.5%) of these papers met inclusion criteria or not. This corresponded to a kappa value of 0.504, indicating a moderate level of agreement between reviewers [58]. Full-text screening of the 862 papers published in English was conducted independently by two reviewers. They agreed on whether 820 (95.1%) presented empirical data or not, which corresponded to a kappa value of 0.717, indicating substantial inter-reviewer reliability [58]. Structure of the review The systematic review procedure identified 48 papers that presented studies of non-fatal suicidal behaviour or psychosocial problems in veterinary surgeons. Three papers reported more than one study [3, 14, 27]. Therefore, 52 studies in total are included in this review. Reported elsewhere are the 19 additional papers on the prevalence of

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Soc Psychiat Epidemiol Table 1 Quality rating scale

Criteria

Score Comments (1/0)*

1 Peer review The article has been peer-reviewed

1

The article has not been peer-reviewed

0

2 Aims The aims of the study in relation to wellbeing are clearly stated

1

The aims of the study in relation to wellbeing are not clearly stated

0

3 Information on response rate The response rate is stated and/or sufficient information is provided to calculate the 1 response rate The response rate is not stated and insufficient information is available to calculate it 0 4 Response rate data The response rate is greater than or equal to 50%

1

The response rate is less than 50% or is not stated

0

5 Sample demographics (gender) The proportion of males in the sample is stated

1

The proportion of males in the sample is not stated

0

6 Sample demographics (age) The age distribution of the sample is stated

1

The age distribution of the sample is not stated

0

7 Validity and reliability of each measure The validity or external reliability of at least one measure is reported

1

The validity or external reliability is not reported for any of the measures

0

8 Number of items in each measure More than one item is used to assess at least one issue of wellbeing One item is used to assess each issue of wellbeing, or the number of items is not stated

1 0

9 Prevalence of problem The study reports the prevalence of at least one issue of wellbeing

1

The study does not report the prevalence of an issue of wellbeing

0

10 Statistical comparisons The study makes statistical comparisons with a control group, e.g. medical practitioners The study does not make statistical comparisons with a control group

1 0

11 Limitations of the methodology (authors) The authors discuss limitations of the research methodology

1

The authors do not discuss limitations of the research methodology

0

12 Limitations of the methodology (reviewers) The reviewers cannot identify limitations of the research methodology * Where insufficient information is available, score ‘0’

The reviewers identify limitations of the research methodology

suicide in the veterinary profession [72] and 22 papers on suicidal behaviour and psychosocial problems in veterinary students (Mellanby et al., in prep). Of the 52 studies of nonfatal suicidal behaviour or psychosocial problems in veterinary surgeons, 11 were of relatively high quality as defined by scores 9–12 on the quality rating scale (Table 2). We place greatest emphasis on the results of these studies.

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1 0 /12

Non-fatal suicidal behaviour Five studies presented data on attempted suicide or suicidal ideation in veterinarians in France [14], New Zealand [30], Australia [27], and Ireland [19, 57]. Four studies involved questionnaires [14, 19, 30, 57] and two used interviews [14, 27]. The quality of the studies varied from 3/12 to 10/12.

Soc Psychiat Epidemiol Table 2 Summary of studies of high quality (quality rating score 9–12) Authors and location

Quality rating

Description of sample and methods

Issues of wellbeing reported

Kahn and Nutter [51], UK

11

Cross-sectional postal survey completed by 35 veterinary surgeons (response rate = 70%). 60% were male and the age range was 21–55 years

Mental health difficulties

Cross-sectional postal survey completed by 457 members of the American Association of Equine Practitioners in private practice (response rate = 51%). 45% were male and all were aged 25 years or older

Stress and burnout

Stress and burnout Occupational difficulties Psychological characteristics

Welsch [90], USA

11

Occupational difficulties Psychological characteristics

Bourdet-Loubere [14], France

10

Cross-sectional postal survey completed by 94 veterinarians (response rate = 81.7%). 62.8% were male. Mean age was 41.5 years and ranged from 25 to 63

Non-fatal suicidal behaviour Mental health difficulties

Fairnie [27], Australia

10

Cross-sectional postal survey completed by 419 veterinarians on the Veterinary Registration Board in Western Australia (response rate = 43%). 49% were male and mean age was 42 years Cross-sectional survey completed by 216 French-speaking veterinary surgeons in Belgium (response rate = 9%). 75.5% were male and all participants were aged 25 years or older


Hansez et al. [33], Belgium

Wessells [91], USA

10

Occupational difficulties Drug and alcohol use Psychological characteristics Stress and burnout Occupational difficulties

10

Intervention study to test the effect of a stress reduction programme on work-related anxiety levels. Participants were 10 staff members from emergency veterinary clinics (response rate = 100%). No information on gender distribution was available. Participants were in their ‘early twenties to early thirties’


Elkins and Kearney [25], USA

9

Cross-sectional postal survey completed by 572 veterinarians on the American Veterinary Medical Association database (response rate = 57.2%). All participants were female and mean age was 34 years

Stress and burnout

Gardner and Hini [30], New Zealand

9

Cross-sectional postal survey completed by 849 veterinarians registered with the Veterinary College of New Zealand (response rate = 48.6%). 61.8% were male. No information on age distribution was available

Non-fatal suicidal behaviour Mental health difficulties

Cross-sectional postal survey completed by 231 members of the Australian Small Animal Veterinary Association (response rate = 20%). 44% were male. Mean age was 40.6 years and ranged from 23 to 68


Meehan and Bradley [63], Australia

9

Stress and burnout

Stress and burnout Occupational difficulties

Ptacek et al. [73], USA

9

Cross-sectional survey completed by 62 veterinarians who graduated from Bucknell University or lived in the Harrisburg, Pennsylvania area (response rate = 56.8%). 50% were male. Mean age was 40.1 years and ranged from 26 to 71

Stress and burnout

Wimberley [93], USA

9

Cross-sectional postal survey completed by 242 practising veterinarians who graduated from a large US university (response rate = 40.1%). 54.5% were male. Mean age was 36.3 years and ranged from 26 to 55

Stress and burnout Occupational difficulties

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The two studies of relatively high quality [14, 30] are described below. The first study examined the prevalence of suicidal behaviour in 849 New Zealand veterinary surgeons [30]. Two percent reported that they had attempted to take their life and 16% had thought seriously about it. Female veterinarians and veterinarians working in small animal practice were more likely to report suicidal ideation. Veterinarians who had attempted suicide or thought about it were more likely to use support such as the ‘Vets in Stress’ phone-line, private counselling or spiritual support than those who had not experienced suicidal thoughts or behaviour. In the second study, the reasons for living questionnaire [60] was used to identify the factors that 94 French veterinarians reported would prevent them from taking their life [14]. Beliefs about the need to survive and cope with suicidal thoughts, responsibilities to their family, and childrelated concerns were the most common factors. Less influential were fears of social disapproval, moral objections to suicide or fear of suicide. A fear of suicide was a more salient factor for male than female veterinarians. In the studies of lower quality, it was also found that a relatively large proportion of veterinarians had thought about suicide [27] or knew somebody in the profession who had thought about suicide or died by suicide [14, 19, 57]. In one small survey of Irish veterinarians, all 14 participants knew at least one colleague who had died by suicide [57].

in the past. Depression was more frequently reported by females than males and current depression was reported more frequently by younger females than older females. Those who had experienced depression were more likely to have used the ‘Vets in Stress’ phone line, private counseling or a health professional than those who had not experienced depression and were more likely to use friends and family, and pastoral or spiritual sources for support. In a sample of 94 French veterinarians, approximately 3% reported severe depressive symptoms and 14% severe anxiety [14]. There was a significant positive correlation between anxious and depressive symptoms. Both types of symptoms were more common in those working alone than those working with others. The only intervention study we identified tested the effects of a stress reduction programme on staff working at an emergency veterinary clinic in the USA [91]. Those who did not receive the programme were no more anxious than those who did. In none of the lower quality studies was mental wellbeing reported as being particularly low in the veterinary profession, although direct comparisons with other populations were not made [4, 23, 27, 79, 85]. In one of these studies, foot and mouth disease was found to have had a negative impact on the mental wellbeing of veterinary surgeons in the Netherlands [23]. Stress and burnout

Mental health difficulties Thirteen papers presented data on mental health difficulties. The majority of the studies were questionnaires although one was a database linkage study [27] and another investigated insurance claims [85]. Quality rating scores ranged from 3/12 to 11/12. The six studies of relatively high quality are summarized in Table 3 and described below. Surveys conducted in the UK [51] and Australia [63] found no evidence that mental health was significantly poorer in the veterinary profession than in the general population of the respective countries. A third study found that the percentage of Western Australian veterinarians who were moderately or highly distressed was significantly higher than that of the general population of Western Australia or New South Wales [27]. Psychological distress was significantly higher in female than male veterinarians and in younger veterinarians compared with those over 35 [27]. Current and previous self-reported depression was investigated in a study of 849 New Zealand veterinarians [30]. Around 4% reported they were currently suffering from depression and 12% reported having suffered from it

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Stress and burnout in the veterinary profession were reported in 28 of the studies in the review. The majority of these were conducted in Australia or the USA. Two studies were conducted in each of England, Ireland, Belgium, and Germany, and single studies in Finland, France, the Netherlands, and New Zealand. Questionnaires were used in 26 studies whilst two involved interviews. Quality ratings ranged from 3/12 to 11/12, with eight studies rated as high quality (Table 4). In four high-quality studies of burnout in US veterinarians both males and females experienced acceptable or moderate levels of stress [63, 73, 90, 93]. In contrast, in a study of female veterinarians in the USA, two-thirds experienced early signs of burnout; more than in a comparative male sample [25]. In a study of Belgian veterinarians, 14% experienced high job strain and the same proportion suffered from high levels of burnout, although levels of job satisfaction remained relatively high [33]. In the only study in which veterinarians were compared with members of the general population there were no differences in level of stress [51]. Studies that collected data on methods of coping with stress at work suggested that veterinarians relied on work and home relationships for

Soc Psychiat Epidemiol Table 3 Mental health difficulties in veterinary surgeons Study and location

Mental health issue and measure

Kahn and Nutter General mental health [51], UK Subscale of the occupational stress indicator (OSI) [20] 18 items rated from 1 to 6 (max = 108) Higher score = poorer self-perceived mental health Bourdet-Loubere Depression [14], France Beck Depression Inventory (BDI) [8]

Prevalence of mental health issue and/or contributory factors

Sample mean (SD) = 58.77 (13.92) General population mean (SD) = 55.51 (12.95) T test of difference in means: t = -1.38 (p [ 0.05)

Sample mean = 3.9 and range = 0–21

13 items rated from 1 to 4 (max = 52)

No depression: 61.7%

0–3 = no depression

Those working alone had higher BDI scores (mean = 5.38) than those working with others (mean = 3.15; t = -2.32, p \ 0.02)

4–7 = light depression

Light depression: 20.2%

Moderate depression: 14.9%

Severe depression: 3.2%

8–15 = moderate depression

Beliefs about the need to survive and cope with thoughts of suicide more common in those with lower BDI scores (r = -0.51)

[15 = severe depression

No correlation between BDI score and gender, age, marital status, having children, geographic location, membership to ‘vetos-entraide’ (veterinary support association) or time in practice

Anxiety

State anxiety

State Trait Anxiety Inventory (STAI) [82]

Sample mean (SD) = 37.841 (10.51) and range = 22–69

20 items on state anxiety and 20 items on trait anxiety all rated from 1 to 4 (max = 80 for each scale)

No anxiety: 22.3%

0–29 = no anxiety

Trait anxiety

30–39 = light anxiety 40 = moderate anxiety

Sample mean (SD) = 39.54 (9.1) and range = 27–69 No anxiety: Light Medium High anxiety: Severe 8.5% anxiety: anxiety: 21.3% anxiety: 52.1% 4.3% 13.8%

41–50 = high anxiety 51–80 = severe anxiety

Light anxiety: 44.7%

Medium anxiety: 4.3%

High anxiety: Severe 14.9% anxiety: 13.8%

Those who worked alone had higher trait anxiety (mean = 42.31) than those working with others (mean = 32.11; t = -2.17, p \ 0.03) Beliefs about the need to survive and cope with thoughts of suicide were more common in those with lower state (r = -0.45) and trait (r = -0.42) anxiety Correlation between BDI scores and state (r = 0.7) and trait (r = 0.8) anxiety No correlation between STAI score and gender, geographic location, having children, age, marital status, membership with ‘vetos-entraide’ or length of time in practice


Psychological Distress (PD) K10 [55] 10 items about previous 4 weeks rated on a 5point scale Scores over 30 indicate likely severe mental disorder

Low PD = 47%

Moderate High PD = 32% PD = 17%

Very high PD = 5%

Percentage scoring above 15 = 56% Higher levels of depression than in New South Wales (v2 = 55.09, p \ 0.001) and Western Australia (v2 = 91.34, p \ 0.001) High/very high PD more frequent in females (27%) than males (16%; v2 = 9.828, p \ 0.05)

10–15 = low PD 16–21 = moderate PD 22–29 = high PD 30-50 = Very high PD

Those under 35 experienced more distress than those who were older (v2 = 20.510, p \ 0.001) PD associated with hours worked, risk-taking following graduation, having a back injury in past 5 years, drug taking in past 12 months, anger, unhappiness and job satisfaction Best predictors of PD were back injury in past 5 years, taking drugs in past 12 months and being \ 35 years old

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Soc Psychiat Epidemiol Table 3 continued Study and location

Mental health issue and measure

Wessells [91], USA

Effects of a stress reduction programme on anxiety

Prevalence of mental health issue and/or contributory factors

State Trait Anxiety Inventory (STAI) [82]

Mean pre-treatment trait anxiety for whole sample = 34.6

20 items on state anxiety rated from 1 to 4 (max = 80)

Experimental group mean pre-treatment state anxiety = 38.2

Experimental group mean posttreatment state anxiety = 32.6

20 items on trait anxiety rated from 1 to 4 (max = 80)

Control group mean pre-treatment state anxiety = 41.6

Control group mean post-treatment state anxiety = 35.6

ANCOVA tests found no significant difference between groups in posttreatment state anxiety when pre-test anxiety, trait anxiety and empathy were controlled for as well as when pre-treatment anxiety alone was controlled for Gardner and Hini Depression [30], New Multi-item measure of depressive symptoms Zealand

Currently suffering from depression: 4.1%

Diagnosed with depression at some point: 11.9%

Women more likely to report current depression (v2 = 17.95, p \ 0.001) and depression at some point (v2 = 11.91, p \ 0.01) than men Current depression more frequent in younger than older women (v2 = 35.63, p = 0.003) Those in small animal practice currently experiencing depression more than those in other areas (v2 = 16.99, p \ 0.01) More forms of support used by those currently experiencing depression (t544 = 3.34, p = 0.001) and those diagnosed with depression at some point (t549 = 6.36, p \ 0.001) Vets in Stress phone-line: phone-line was used more by those currently experiencing depression (v2 = 6.27, p = 0.03) and those who had experienced depression before (v2 = 10.19, p = 0.005) Health professionals: used for support more by those currently experiencing depression (v2 = 44.89, p \ 0.001) and those who had experienced depression at some point (v2 = 146.11, p = 0.001) than those who had not Private counselling: used more by those currently experiencing depression (v2 = 22.58, p \ 0.001) and who had experienced depression at some point (v2 = 106.42, p \ 0.001) Support from family and friends: used more by those who had experienced depression at some point than those who had not (v2 = 4.91, p = 0.02) Spiritual/pastoral support: used more by those who had experienced depression at some point than those who had not (v2 = 6.74, p = 0.009) Meehan and Bradley [63], Australia

General mental health GHQ-12 [32]

Mean score (SD) = 4.23 (0.76)

12 items rated on a 6 point scale (max = 72)

Mental health was no lower than in the general population (data not reported) Significant negative correlation with job stress (p \ 0.001)

support more than members of the general population [51]. It was also found that veterinarians used informal forms of support more frequently than professional sources [30].

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Causes of stress were often related to work. Common stressors included managerial aspects of veterinary work [25, 51], long hours [25, 30, 90] and client relations [25,

Soc Psychiat Epidemiol Table 4 Stress and burnout in veterinary surgeons Study and location

Measure of stress or burnout

Prevalence of stress or burnout

Contributory factors

Kahn and Nutter [51], UK

Occupational Stress Indicator [20]

57.1% had encountered a majorly stressful event in the past year that had an important effect on them

Source of pressure

One item measured frequency of stressful events

The sub-scale ‘sources of pressure at work’ contained 61 items (rated on a 6 point scale) to assess the contribution to stress of 6 factors

Welsch [90], Burnout measure [70] USA Frequency of 21 ‘feelings’ rated 1–7 and mean per item calculated (max = 7) 1–2 = low burnout

Mean (SD) = 3.29 (0.8) Male mean (SD) = 3.07 (0.8) Female mean (SD) = 3.47 (0.8)

Mean Mean (SD) in (SD) general in population sample 31.8 30.22 (6.48) (7.37)

Factors intrinsic to the job Managerial 35.87 35.55 (8.47) role (8.59) Relationships 30.46 30.31 (7.71) with other (8.10) people Career and 23.11 28.40 (8.11) achievement (7.25) Organizational 34.86 38.99 (9.21) structure and (9.99) climate Home/work 32.94 30.00 (10.26) interference (11.24) Factors significantly more stressful in the general population than in the veterinary sample: ‘career and achievement’ (mean = 28.40 vs. mean = 23.11, t = 4.3, p \ 0.0005); ‘organizational structure and climate’ (mean = 38.99 vs. mean = 34.86, t = 2.44, p \ 0.01) Job stress and burnout were correlated (r = 0.54, p \ 0.0001) Hours worked was correlated with burnout Older age, increased years in the profession, increased years in the job and increased income were associated with less burnout Women reported higher levels of burnout (mean = 3.47, SD = 0.8) than men (mean = 3.07, SD = 0.8) Higher levels of burnout were associated with emotional coping strategies whereas lower levels of burnout were associated with rational and detached coping strategies

2–3 = acceptable levels of stress and manageable work dissatisfaction 3–4 = beginning of burnout syndrome 4–5 = clinical burnout 5–7 = severe problems Health Professions Stress Inventory [94] Mean (SD) = 7.01 (2.7) Effect of stress on burnout is moderated by emotional coping in men 30 stressful job situations rated in frequency on 5 point scale (max = 25) Hansez et al. Stress ‘Job engagement’ sub-scale mean Main sources of stress (from open ended (sd) = 54.06 (8.89) question): 1. Client relations, 2. Working [33], (1) Positive and Negative Occupational Stress Belgium time management, 3. Occupational risks Inventory (PNOSI) [34] Normal or high job engagement: 95.4% Major sources of stress (from VSI): 1. 19 items rated 1–4 to measure frequency of job Emergency time/working management, 2. engagement and job strain (max = 76) Client relations \40 = Low job engagement ‘Job strain’ sub-scale mean Job strain was higher in men than women (SD) = 52.19 (8.15) (p = 0.01) 40–60 = Moderate scores High job strain: 14.8% Small animal vets had lower job strain than mixed practitioners (p = 0.04) [60 = Severe job strain (2) Open ended questions (3) Veterinary Stress Inventory (VSI) [9] Burnout High burnout: 14.4% Burnout was higher in men than women (p = 0.05) Sub-scale of PNOSI [34] 9 items rated in frequency on 7 point scale

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Elkins and Kearney [25], USA

Burnout self-diagnosis instrument [71]

Sample mean = 3.4 (range = 1.81–6.14)

Frequency of 21 symptoms rated 1–7 and mean per item calculated (max = 7) 1–2 = low levels of stress and dissatisfaction with work 2–3 = acceptable levels of stress and job satisfaction 3–4 = beginnings of burnout syndrome 4–5 = clinical burnout 5–6 = burnout where professional counselling needed 6–7 = severe burnout and probable impairment of professional performance Specific stressors were also ranked in frequency

Gardner and Hini [30], New Zealand

Contributors to stress assessed by a list of 10 work-related factors, 6 skill and expertise related factors, and 11 personal factors rated 1–7


Items from the Job Content Questionnaire [52] 12 items (8 about psychological work demands/ stress) rated 1- 5 (strongly agree to strongly disagree). Mean score per item calculated.

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Most common stressors 1. managing the practice 2. economic concerns Mean in comparison male veterinarian 3. client relations sample = 3.09 [26] 4. lay staff relationships 5. professional relationships Proportion who scored [3: 67% 6. personal/family relationships Proportion who scored [ 3 in Women who worked [40 h per week and comparison male veterinarian sample: found their job stressful were more likely 53% [26] to be burnt out 83% agreed/strongly agreed with the statement: ‘I am happy in my current position’ 79% of a sample of female veterinarians Those who were not involved in the in Texas were happy in their current ownership of the practice were more job [7] burnt out 71% agreed/strongly agreed with the statement: ‘If I had to chose again I would chose the veterinary profession’ 87% agreed/strongly agreed with the statement: ‘I consider my position stressful’ 80% agreed/strongly agreed with the statement: ‘Women are treated equally to men in the veterinary profession’ Major sources of stress: Hours worked, client expectations, and unexpected outcomes Major skills and expertise stressors: Ability to keep up with new knowledge, level of technical skills and ability to keep pace with technology Major personal factors stressors: Living up to one’s own expectations Males who were younger experienced more stress in general (v2 = 49.70, p \ 0.002), more stress on a typical day (v2 = 71.87, p \ 0.001) and more stress from their most stressful situation at work (v2 = 80.79, p \ 0.001) than those who were older Those in larger organizations were more stressed in a typical working day than those in smaller organizations (v215 = 33.41, p \ 0.001) Sample mean = 3.47





Ptacek et al. [73], USA

40–50 min questionnaire about delivering bad news

Mean score per item = 3.5, i.e. ‘moderately stressful’

Preparation anxiety (mean) = 3 Overall stress (mean) = 3.38 Perceived client stress (mean) = 4.32

Several stressful situations, each rated 1–5 and mean score per item calculated (max = 5)

Mean score per item for specific aspects of the transaction measured

Wimberley [93], USA

Subscale of Career/Marital Stress of Women Inventory [86]

Mean score (SD) males = 27.77 (6.9) Mean score (SD) females = 28.50 (6.55)

15 items that measure effect of work stress on career rated 1–4 scale (max = 60)

Higher scores indicate greater impact

30, 33]. Data from studies investigating additional occupational difficulties are described below. Occupational difficulties In a preliminary survey of the literature we identified 12 areas of potential occupational stress for veterinary surgeons: (1) working hours, (2) workload, (3) financial issues, (4) client demands/expectations, (5) work-life balance, (6) area of work, (7) euthanasia, (8) professional support, (9) job satisfaction, (10) career change (either within the profession or to another profession), (11) general work-related stress, and (12) ‘other’ factors. Thirty-six studies presented data on at least one of these issues. The studies were largely conducted in the UK (N = 11), Australia (N = 10) or USA (N = 8). Two studies were conducted in Belgium (N = 2) and single studies were conducted in Finland, France, Germany, Ireland, and New Zealand. Questionnaires were used in 33 studies,

Delivery stress (mean) = 2.89 Length of stress (mean) = 2.32 Lowered own stress (mean) = 3.36 Lowered client stress Perceived client (mean) = 3.38 satisfaction (mean) = 4.15 Males experienced significantly lower levels of stress (mean = 3.13) than females (mean = 3.65; t(60) = 2.07, p = 0.043) Stress lasted longer in women than men (t(60) = -2.31, p = 0.024) Stressors with biggest impact (mean, SD): ‘emergency calls outside office hours’ and ‘other’ for males (0.972, 2.70) and females (1.008, 2.94), respectively Stressors with smallest impact for males (mean, SD): physical danger of working with animals (1.92, 0.856), abuse of animals by owners (1.92, 0.742), emotional strain caused by euthanasia (1.92, 0.844) Stressor with smallest impact for females (mean, SD): physical danger of working with animals: 2.06 (0.773) The unwillingness of owners to have recommended procedures carried out caused significantly greater stress for females than males, as did emotional strain due to euthanasia of animals and abusive behaviour of animals by owners. Responsibility of owning and managing their own business caused significantly greater stress for males than females

interviews in two [21, 54] and a combination of both methods in one [76]. Quality ratings ranged from 3/12 to 11/12. Six studies were of relatively high quality (Table 5). These studies reported on working hours, workload, worklife balance, euthanasia, and job satisfaction and are described below. Results of three high-quality studies suggested that veterinarians work 44–54 h per week [27, 33, 63]. As noted above, increased working hours, consultations, or surgeries were associated with increased stress [63]. The effect of work-life balance on wellbeing in the veterinary profession was investigated in two high-quality studies [33, 63]. In both, veterinary working life was found to have more of a negative effect on home life than in other professions [33]. Imbalance between work and home life was also significantly correlated with increased stress [63]. The second study was also the only high quality one to present data on the impact on veterinary wellbeing of performing euthanasia [63]. More frequent small animal euthanasia was

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123

Euthanasia

Work-life balance

Workload

Mean Pos WHI (SD): 1.17 (1.15)

Measures positive (pos)

Meehan and Bradley Self-report [63], Australia Mean number of euthanasias per week (SD)

4.84 (4.03)

Not reported

and negative (neg) work-home Mean Pos HWI (SD): 1.21 interactions (WHI) and (0.72) home-work interactions Belgian vets had significantly (HWI) higher Neg WHI than other Dutch and Belgian samples (p \ 0.001 and p = 0.0)

Mean Neg HWI (SD): 0.45 (0.42)

27 items rated 0–3 and mean score per item calculated

Survey Work-home Interaction Mean Neg WHI (SD): 1.45 Nijmegen (SWING) [31] (0.55)

Meehan and Bradley 10 statements rated 1–5 [63] Australia


Significant positive correlation with job stress (p \ 0.05)

Significant negative correlation with job stress (p \ 0.001)

Work-life balance identified as a possible contributor to the burnout rate

Neg WHI was more prominent in males than females, and PosWHI was more common in females than males

Bovine and mixed practice vets were significantly more affected by Neg WHI than small animal vets (p \ 0.001, p = 0.001)

Number of hours in surgery was associated with stress (p \ 0.001)

Mean number of hours in surgery per day

3

Number of surgeries was associated with stress (p \ 0.001)

Number of consultations was associated with stress (p \ 0.001)

Work hours were positively correlated with job stress (p \ 0.001)

Being on call had major effect on family life for 40%, no effect for 14%

Being on call out of hours had an effect on energy levels for 24%

Being on call out of hours had a major effect on sleep for 22%, moderate effect for 43% and no effect for 36%

Those in mixed animal practice worked more hours per week (53) than those in small animal practice (38) and large animal practice (45)

Males worked more hours per week (49) than females (39)


Mean number of surgeries per 3.21 day

Meehan and Bradley Mean number of consultations 13.94 (range 0–40) [63], Australia per day

45.03 (14.51)


Mean number of hours worked 44 per week (SD)

Primary data on occupational issue

54.27 (18.75)


Working hours

Measure of issue


Study and location

Occupational issue

Table 5 Occupational difficulties for veterinary surgeons


3.7 (1.0)

Welsch [90], USA

Wimberley [93], USA

15.57

Sources of greatest satisfaction were type of work, co-workers, work conditions and career future

Scale related to 6 aspects of work

Sources of least satisfaction were income and amount of work

Males reported greater job satisfaction (mean = 3.43, SD = 1.07) than females (mean = 3.56, SD = 0.96)

Negative correlation with life stress

Positive correlation with income

Positive correlation with number of years in job

Positive correlation with number of years in the profession

Positive correlation between job satisfaction and age

Males reported more job satisfaction (mean = 3.73) than females (mean = 3.68)

Negative correlation with job stress (r = -0.39, p \ 0.0001)

Negative correlation between job satisfaction and job stress (p \ 0.001)

Physical conditions were the third greatest source of satisfaction

Responsibility was the greatest cause of satisfaction Freedom at work was the greatest cause of satisfaction

Fellow workers were the least cause of dissatisfaction

Third greatest cause of dissatisfaction was working hours

Second greatest cause of job dissatisfaction was pay rate

Greatest cause of dissatisfaction was promotional opportunities/pay rise

Authors link job satisfaction to stress (no data reported)


Index of Organizational Reactions [24]

5 items rated from 1 to 5 (strongly agree to strongly disagree) and mean score (sd) per item calculated (max = 5)

Composite measure of job satisfaction [62]

Higher scores indicate more job satisfaction

22 items

Meehan and Bradley Sample mean score on an un[63], Australia described job satisfaction scale (max = 20)

Questions taken from standard Not reported job satisfaction scale about 11 areas of work [88]

Primary data on occupational issue

Significant difference in job satisfaction between veterinary sample (mean = 90.8, SD = 14.35) and the general population (mean = 82.08, SD = 16.6; t = -3.58, p \ 0.0005)


Job satisfaction

Measure of issue

Kahn and Nutter [51], Subscale of the Occupational UK Stress Indicator (OSI) [20]

Study and location

Occupational issue

Table 5 continued


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associated with increased levels of stress. On average small animal veterinary surgeons in Australia performed euthanasia around 4–5 times per day. Mean scores on various job satisfaction scales were presented in five studies [27, 51, 63, 90, 93]. In one study, UK veterinary surgeons were found to be more satisfied with work than members of the general population [51]. Increased levels of job satisfaction were reported in males [63, 90], older veterinarians, and those who had been in the profession the longest [90]. Job satisfaction was strongly correlated with reduced stress levels [27, 63, 90]. Income was reported as a source of dissatisfaction in two of the studies [27, 93]. Studies of lower quality provided data about additional occupational difficulties such as level of professional support [43, 44, 65, 74] and career changes within or from the profession [3, 27, 42, 44, 45, 54, 76]. However, explicit links with wellbeing were rarely made and no comparative data presented. Reasons for leaving the profession included heavy workload or long hours, lack of support, lack of challenge and a need for more work-life balance. Psychological characteristics Four studies presented data on psychological characteristics that might be associated with wellbeing and three scored 9 or more on the quality rating scale [27, 51, 90]. They presented data on personality, mood and coping styles. One high-quality study from the UK [51] sought to test the suggestion that veterinary surgeons experience increased stress because the veterinary profession attracts individuals with ‘Type A’ personality [89]. Type A personality is characterized by competitiveness, ambitiousness, aggressiveness and controlling behaviour and has been associated with stress-related illnesses and cardiovascular disease [13]. There was no evidence that Type A behaviour was more prevalent in UK veterinary surgeons than in the general population. However, veterinarians had a greater internal locus of control (attributing successes and failures to their own personal performance rather than external factors) [51]. In another study, the majority of a sample of Australian veterinarians (84%) reported being ‘happy’ and only 5% were ‘angry on a regular basis’ [27]. The final study investigated coping styles. Male veterinarians used more rational and detached methods of coping with stress, whereas female veterinarians were more likely to use emotional coping strategies [90].

Discussion This review included 52 studies (from 48 papers) which investigated non-fatal suicidal behaviour and psychosocial

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problems in qualified veterinary surgeons. The quality rating scale we developed enabled us to place emphasis on the findings of the studies of highest quality (N = 11). One of the higher quality studies of suicidal behaviour suggested that around 2% of vets have attempted to take their life and 16% have seriously thought about it [30]. Another investigated protective factors against suicide and found that veterinary surgeons were influenced more by a sense of responsibility to their families and beliefs about the need to cope with suicidal thoughts, than by a fear of suicide or moral objection to it [14]. None of the studies in the review investigated the factors directly contributing to suicidal behaviour in the profession. However, many reports included data on issues of wellbeing more generally associated with suicidal behaviour. Consistent with a recent study of farmers [49], we found little evidence that veterinary surgeons have particularly poor mental health or suffer from exceptionally high levels of stress. The studies in the review identified subgroups of the veterinary profession that were more likely to experience difficulties of wellbeing. Female veterinarians [30], younger veterinarians [27] and those working alone rather than with others [14], were identified as being more at risk of suicidal thoughts, mental health difficulties and stress. Occupational issues associated with higher levels of stress included the managerial aspects of the job, long working hours, heavy workload, poor work-life balance, difficult client relations, and performing euthanasia. Veterinarians with poorer mental health or those suffering from stress tended to use informal methods of support rather than professional sources [30, 51]. Studies of alcohol and drug misuse in the veterinary profession are infrequent [21, 27, 47, 75]. However, the results of one study suggest that veterinary surgeons may be more likely than physicians to use drugs to cope with stress [21]. Another found that around 6.5% of Australian veterinarians engaged in ‘risky’ alcohol use and a minority of respondents reported using non-prescribed tranquilisers or sleeping tablets (8%), marijuana (6%), ecstasy (4%) and ketamine (1%) [27]. In addition, 7% reported using anti-depressants. Since the review was conducted the authors are aware of additional surveys of mental wellbeing in the veterinary profession in the UK [6], Australia [28, 81], and Germany [35]. One report suggests that mental health may be poorer in the veterinary profession than in the general population [6]. These studies generally lend further support to the review’s findings that young and female veterinarians are at greatest risk of mental health problems [28]. The review findings also support the hypothetical model of suicidal behaviour proposed by Bartram and Baldwin [5]. Evidence of specific occupational difficulties, of differential attributional styles, and of the negative impact of performing euthanasia, support a complex and interactive model of


suicidal behaviour in the veterinary profession. However, comparative studies in the review failed to find differences in wellbeing between veterinary surgeons and members of the general population. Therefore, other aspects proposed in the hypothetical model may require further research before causal pathways can be implicated. Strengths and limitations The review highlights the paucity of research investigating the factors that are likely to contribute to suicide in the veterinary profession. Studying non-fatal suicidal behaviour is one approach to understanding more about the risk factors associated with suicide, yet just six studies of this kind have been conducted with veterinary surgeons. Studies to date have tended to be profession-wide surveys of the prevalence of suicidal thoughts and behaviour rather than in-depth studies of those within the profession who have previously engaged in suicidal behaviour. Another limitation of the studies in the review is the small proportion of relatively high quality. The rating scale we developed contained 12 relatively fundamental items including peer review, response rate information, validity of measures, and comparisons with a control group (Table 1). Just 11 out of 52 studies obtained a score of nine or above. Aspects of poorer quality in many of the studies included the lack of appropriate measures and low response rates. This can reduce the reliability and validity of research findings and limits the ability to make comparisons with other populations. Multi-item measures that have validity and reliability in similar samples should be used wherever possible. Also, when studying mental health difficulties, inclusion of diagnostic measures as well as scales would be informative. The process of assimilating studies in a systematic review must also be carried out in a reliable and valid way. The search strategy in the review involved electronic and non-electronic methods, multiple search terms and no restrictions on language in order to be as inclusive as possible. At both the abstract screening and full-text level, moderate to substantial agreement between reviewers suggested that inter-reviewer reliability had not been compromised by the broad inclusion criteria. The use of a quality rating scale prevented too much emphasis being placed on studies that were likely to be unreliable. However, it is acknowledged that the assignment of labels to particular scores was to a certain degree arbitrary and that studies of ‘high quality’ may still include methodological weaknesses. It was beyond the scope of the review to assess the validity and reliability of the scale. Future research might involve testing and developing the measure to improve its use in assessing quality of studies in reviews of this nature.

Future research In future studies of suicidal behaviour and psychosocial problems in veterinary surgeons, alternative designs should be considered. The majority of studies in the review were cross-sectional, whereas longitudinal, retrospective or prospective designs may help determine the direction in which various risk factors operate. For example, longitudinal studies may help understand the extent to which experiencing mental health difficulties affects later risk of suicidal behaviour. Similarly, retrospective studies also enable researchers to understand the events and pathways that led to a crisis point. Evaluation of interventions to improve wellbeing in the veterinary profession could also be a valuable area for future research. Finally, one method that has been used to study suicide in other high risk occupational groups is the psychological autopsy approach [36, 41]. This involves examining the coroners’ records for cases of suicide in the population of interest, and where possible interviewing relatives and other informants [39]. Access to these data provides a unique opportunity to identify the risk factors that might be relevant for suicide in veterinarians.

Conclusions The review identified interesting findings that could have important practical implications for prevention of suicide in the veterinary profession. One study found that elevated levels of stress were associated with performing euthanasia [63]. Further investigation of the exact nature of this relationship may have implications for how veterinarians frequently performing euthanasia are supported. Similarly, the findings of a French study suggest that veterinarians are more protected from suicide by a desire to cope than by fears of suicide or moral objections to it [14]. Given that veterinarians may be motivated to overcome suicidal thoughts, teaching more effective cognitive and behavioural coping strategies may be particularly effective. In addition, the review suggests that female veterinarians who are at a relatively early stage in their career are more likely to suffer from poor mental wellbeing than older male veterinarians. Strategies that target subgroups of the profession that are especially at risk may therefore be indicated. More generally, the review demonstrates that there are multiple factors that may contribute to suicidal behaviour in the veterinary profession and therefore that suicide prevention strategies should take a holistic approach. It is unlikely that simply restricting access to lethal agents will be effective in preventing suicide, even if this were feasible. An approach that acknowledges the importance of occupational and psychosocial factors

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associated with suicidal behaviour in the veterinary profession is likely to be most effective at improving mental wellbeing in the profession and ultimately, reducing the number of cases of suicide. Acknowledgments The authors wish to acknowledge Lesley Sutton (LS) and Louise Harriss (LH) who assisted in the abstract and fulltext screening stages of the review. Helen Fairnie, Keren Skegg, Austin Kirwan, Lin Fritschi and Rosie Allister, as experts in the field, identified references omitted from the search prior to full-text screening. This work was supported by Hill’s Pet Nutrition; the Royal College of Veterinary Surgeons Trust Fund; and the Veterinary Benevolent Fund (VBF). Keith Hawton is funded by Oxfordshire and Buckinghamshire Mental Health NHS Foundation Trust and the National Institute for Health Research, for which he is a Senior Investigator. Sue Simkin is funded by an NIHR Programme Grant RP-PG-0606-1247 [‘‘A multi-centre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England’’], for which Keith Hawton is a lead investigator. Conflict of interest The authors declare that they have no conflict of interest. The views and opinions expressed are those of the authors and do not necessarily represent those of the funding bodies.

References 1. Agerbo E, Gunnell D, Bonde JP, Mortensen PB, Nordentoft M (2007) Suicide and occupation: the impact of socio-economic, demographic and psychiatric differences. Psychol Med 37:1131– 1140. doi:10.1017/S0033291707000487 2. Andersen K, Hawgood J, Klieve H, Kolves K, De Leo D (2010) Suicide in selected occupations in Queensland: evidence from the State suicide register. Aust N Z J Psychiatry 44:243–249. doi: 10.3109/00048670903487142 3. Andrus DM, Gwinner KP, Prince JB (2006) Job satisfaction, changes in occupational area, and commitment to a career in food supply veterinary medicine. J Am Vet Med Assoc 228:1884– 1893. doi:10.2460/javma.228.12.1884 4. Anonymous (2005) DVMs are happy at work and with life. Vet Econ 46:132 5. Bartram DJ, Baldwin DS (2010) Veterinary surgeons and suicide: a structured review of possible influences on increased risk. Vet Rec 166:388–397 6. Bartram DJ, Yadegarfar G, Baldwin DS (2009) A cross-sectional study of mental health and well-being and their associations in the UK veterinary profession. Soc Psychiatry Psychiatr Epidemiol 44:1075–1085. doi:10.1007/s00127-009-0030-8 7. Beaver B (1990) Attitudes about veterinary medicine in Texas: part 1—a professional profile. Tex Vet Med J 3:17–33 8. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An inventory for measuring depression. Arch Gen Psychiatry 4:561–571 9. Biron O (2006) Stress in veterinary surgeons. Dissertation, University of Liege, Belgium 10. Blachly PH, Osterud HT, Josslin R (1963) Suicide in professional groups. N Engl J Med 268:1278–1282 11. Blair A, Hayes HM (1982) Mortality patterns among United States veterinarians, 1947–1977—an expanded study. Int J Epidemiol 11:391–397 12. Blair A, Hayes HM (1980) Cancer and other causes of death among U.S. veterinarians, 1966–1977. Int J Cancer 25:181–185 13. Booth-Kewley S, Friedman HS (1987) Psychological predictors of heart disease: a quantitative review. Psychol Bull 101:343–362

123

14. Bourdet-Loubere S (2006) Study of links between suicidal behaviour, reasons for living, anxiety and depression in a sample of 94 veterinary surgeons. Masters thesis, University of Toulouse II-Mirial 15. Boxer PA, Burnett C, Swanson N (1995) Suicide and occupation: a review of the literature. J Occup Environ Med 37:442–452 16. Charlton J (1995) Trends and patterns in suicide in England and Wales. Int J Epidemiol 24(Suppl 1):S45–S52 17. Charlton J (1993) Suicide deaths in England and Wales: trends in factors associated with suicide deaths. Popul Trends 71:34–42 18. Cohidon C, Santin G, Geoffroy-Perez B, Imbernon E (2010) Suicide and occupation in France. Rev Epidemiol Sante Publique. doi:10.1016/j.respe.2010.01.001 19. Connolly D (2004) Stress in the veterinary profession. Ir Vet J 57:315–316 20. Cooper CL, Sloan SJ, Williams S (1988) Occupational stress indicator. NFER Nelson, Windsor 21. Crowther B, Felkner L, McDaniel O (1977) Differences among medical professionals in their attitude toward drugs. Int J Addict 12:43–52 22. Department of Health (2002) National suicide prevention strategy for England. Her Majesty’s Stationery Office, London 23. Driijfhout AC, de Leeuw JR (2005) The mental health status of local veterinarians, 2 years after the foot and mouth disease crisis in their practice. Tijdschr Diergeneeskd 130:82–85 24. Dunham RB, Smith FJ (1979) Organizational surveys: an internal assessment of organizational health. Scott Foresman and Company, Dallas 25. Elkins AD, Kearney M (1992) Professional burnout among female veterinarians in the United States. J Am Vet Med Assoc 200:604–608 26. Elkins AD, Elkins JR (1987) Professional burnout among U.S. veterinarians: how serious a problem? Vet Med 82:1245–1250 27. Fairnie HM (2005) Occupational injury, disease and stress in the veterinary profession. PhD thesis, Curtin University of Technology, Australia 28. Fritschi L, Morrison D, Shirangi A, Day L (2009) Psychological well-being of Australian veterinarians. Aust Vet J 87:76–81. doi: 10.1111/j.1751-0813.2009.00391.x 29. Gallagher LM, Kliem C, Beautrais AL, Stallones L (2008) Suicide and occupation in New Zealand, 2001–2005. Int J Occup Environ Health 14:45–50 30. Gardner DH, Hini D (2006) Work-related stress in the veterinary profession in New Zealand. N Z Vet J 54:119–124 31. Geurts S, Taris TW, Kompier MAJ, Dikkers JSE, Van Hooff MLM, y Kinnunen UM (2005) Work-home interaction from a work psychological perspective: development and validation of a new questionnaire, the SWING. Work Stress 19:319–339 32. Goldberg D (1972) The detection of psychiatric illness by questionnaire. Oxford University Press, London 33. Hansez I, Schins F, Rollin F (2008) Occupational stress, workhome interference and burnout among Belgian veterinary practitioners. Ir Vet J 61:233–241 34. Hansez I, Grisard A, De Keyser V (2004) Organisational changes, job strain among employees and client satisfaction: elaboration of the flexihealth concept, PS/12/29-1999/2003. Internal research report, University of Liege, Belgium 35. Harling M, Strehmel P, Schablon A, Nienhaus A (2009) Psychosocial stress, demoralization and the consumption of tobacco, alcohol and medical drugs by veterinarians. J Occup Med Toxicol 4:4. doi:10.1186/1745-6673-4-4 36. Hawton K, Malmberg A, Simkin S (2004) Suicide in doctors. A psychological autopsy study. J Psychosom Res 57:1–4. doi: 10.1016/S0022-3999(03)00372-6 37. Hawton K, Simkin S, Rue J, Haw C, Barbour F, Clements A, Sakarovitch C, Deeks J (2002) Suicide in female nurses in England and Wales. Psychol Med 32:239–250

Soc Psychiat Epidemiol 38. Hawton K, Clements A, Simkin S, Malmberg A (2000) Doctors who kill themselves: a study of the methods used for suicide. QJM 93:351–357 39. Hawton K, Appleby L, Platt S, Foster T, Cooper J, Malmberg A, Simkin S (1998) The psychological autopsy approach to studying suicide: a review of methodological issues. J Affect Disord 50:269–276 40. Hawton K, Fagg J, Simkin S, Harriss L, Malmberg A (1998) Methods used for suicide by farmers in England and Wales. The contribution of availability and its relevance to prevention. Br J Psychiatry 173:320–324 41. Hawton K, Simkin S, Malmberg A, Fagg J, Harriss L (1998) Suicide and stress in farmers. The Stationary Office, London 42. Heath TJ (2007) Longitudinal study of veterinary students and veterinarians: the first 20 years. Aust Vet J 85:281–289. doi: 10.1111/j.1751-0813.2007.00172.x 43. Heath TJ (2005) Recent veterinary graduates over the last five decades: recollections and perceptions. Aust Vet J 83:682–687 44. Heath TJ (2002) Longitudinal study of veterinarians from entry to the veterinary course to ten years after graduation: career paths. Aust Vet J 80:468–473 45. Heath TJ (1998) Length of veterinary working life. Aust Vet J 76:478–481 46. Hem E, Haldorsen T, Aasland OG, Tyssen R, Vaglum P, Ekeberg O (2005) Suicide rates according to education with a particular focus on physicians in Norway 1960–2000. Psychol Med 35:873–880 47. Jeyaretnam J, Jones H, Phillips M (2000) Disease and injury among veterinarians. Aust Vet J 78:625–629 48. Jones-Fairnie H, Ferroni P, Silburn S, Lawrence D (2008) Suicide in Australian veterinarians. Aust Vet J 86:114–116. doi: 10.1111/j.1751-0813.2008.00277.x 49. Judd F, Jackson H, Fraser C, Murray G, Robins G, Komiti A (2006) Understanding suicide in Australian farmers. Soc Psychiatry Psychiatr Epidemiol 41:1–10 50. Kaga M, Takeshima T, Matsumoto T (2009) Suicide and its prevention in Japan. Leg Med (Tokyo) 11(Suppl 1):S18–S21. doi: 10.1016/j.legalmed.2009.01.015 51. Kahn H, Nutter CVJ (2005) Stress in veterinary surgeons: a review and pilot study. In: Antoniou AG, Cooper CL (eds) Research companion to organizational health psychology. Edward Elgar Publishing, Northampton, pp 293–303 52. Karasek RA (1985) Job content questionnaire and user’s guide. Department of Work Environment, University of Massachusetts Lowell, Lowell 53. Kelly S, Bunting J (1998) Trends in suicide in England and Wales, 1982–96. Popul Trends 92:29–41 54. Kerr SR (1995) Attrition from the veterinary profession: twelve case studies. Dissertation, Kansas State University 55. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, Walters EE, Zaslavsky AM (2002) Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med 32:959–976 56. Kinlen LJ (1983) Mortality among British veterinary surgeons. Br Med J (Clin Res Ed) 287:1017–1019 57. Kinsella M (2006) Suicide in the veterinary profession: the hidden reality-part two. Ir Vet J 59:704–706 58. Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174 59. Lange WR, Frankenfield DL, Carico J, Pfeiffer MB, Snyder FR, Van Der Decker J (1992) Deaths among members of the Public Health Service Commissioned Corps, 1965–89. Public Health Rep 107:160–166 60. Linehan MM, Goodstein JL, Nielsen SL, Chiles JA (1983) Reasons for staying alive when you are thinking of killing yourself: the reasons for living inventory. J Consult Clin Psychol 51:276–286

61. Mammerickx M (1985) Portrait of the contemporary Belgian veterinarian II Mortality level, life hope and death causes. Ann Med Vet 129:505–512 62. Martin J, Shehan C (1989) Education and job satisfaction. The influences of gender, wage-earning status, and job values. Work Occup 16:184–199 63. Meehan MP, Bradley L (2007) Identifying and evaluating job stress within the Australian small animal veterinary profession. Aust Vet Pract 37:70–83 64. Mellanby RJ (2005) Incidence of suicide in the veterinary profession in England and Wales. Vet Rec 157:415–417 65. Mellanby RJ, Herrtage ME (2004) Survey of mistakes made by recent veterinary graduates. Vet Rec 155:761–765 66. Meltzer H, Griffiths C, Brock A, Rooney C, Jenkins R (2008) Patterns of suicide by occupation in England and Wales: 2001–2005. Br J Psychiatry 193:73–76. doi:10.1192/bjp.bp.107.040550 67. Milham S, Ossiander E (2001) Occupational Mortality in Washington State (1950–1999). https://fortress.wa.gov/doh/ occmort/Default.aspx. Accessed 11 June 2010 68. Miller JM, Beaumont JJ (1995) Suicide, cancer, and other causes of death among California veterinarians, 1960–1992. Am J Ind Med 27:37–49 69. O’Connor RC (2007) The relations between perfectionism and suicidality: a systematic review. Suicide Life Threat Behav 37:698–714. doi:10.1521/suli.2007.37.6.698 70. Pines A, Aronson E (1988) Career burnout: causes and cures. The Free Press, Division of Macmillan, New York 71. Pines A, Maslach C (1978) Characteristics of staff burnout in mental health settings. Hosp Community Psychiatry 29:233–237 72. Platt B, Hawton K, Simkin S, Mellanby RJ (2010) Systematic review of the prevalence of suicide in veterinary surgeons. Occup Med 60:436–446. doi:10.1093/occmed/kqq044 73. Ptacek J, Leonard K, McKee TL (2004) ‘I’ve got some bad news’: veterinarians’ recollections of communicating bad news to clients. J Appl Soc Psychol 34:366–390 74. Riggs EA, Routly JE, Taylor IR, Dobson H (2001) Support needs of veterinary surgeons in the first few years of practice: a survey of recent and experienced graduates. Vet Rec 149:743–745 75. Roesner J (2007) The unlikely face of addiction. Vet Econ 48:73–75 76. Routly JE, Taylor IR, Turner R, McKernan EJ, Dobson H (2002) Support needs of veterinary surgeons during the first few years of practice: perceptions of recent graduates and senior partners. Vet Rec 150:167–171 77. Sanderson S, Tatt ID, Higgins JPT (2007) Tools for assessing quality and susceptibility to bias in observational studies in epidemiology: a systematic review and annotated bibliography. Int J Epidemiol 36:666–676. doi:10.1093/ije/dym018 78. Schnurrenberger PR, Martin RJ, Walker JF (1977) Mortality in Illinois veterinarians. J Am Vet Med Assoc 170:1071–1075 79. Shouksmith G, Hesketh B (1986) Changing horses in mid-stream: job and life satisfactions for veterinarians. N Z Vet J 34:141–144 80. Skegg K, Firth H, Gray A, Cox B (2010) Suicide by occupation: does access to means increase the risk? Aust N Z J Psychiatry 44:429–434. doi:10.3109/00048670903487191 81. Smith DR, Leggat PA, Speare R, Townley-Jones M (2009) Examining the dimensions and correlates of workplace stress among Australian veterinarians. J Occup Med Toxicol 4:32. doi: 10.1186/1745-6673-4-32 82. Spielberger CD, Gorsuth RL, Lushene RE (1970) Manual for the state-trait anxiety inventory (self-evaluation questionnaire). Consulting Psychologists Press, Palo Alto 83. Stark C, Belbin A, Hopkins P, Gibbs D, Hay A, Gunnell D (2006) Male suicide and occupation in Scotland. Health Stat Q 29:26–29 84. Stefansson CG, Wicks S (1991) Health care occupations and suicide in Sweden 1961–1985. Soc Psychiatry Psychiatr Epidemiol 26:259–264

123

Soc Psychiat Epidemiol 85. Stembert FM, Lipman LJ, Loomans JB (2003) Veterinarian: a healthy profession? Tijdschr Diergeneeskd 128:565–569 86. Thomas S, Albrecht K, White P (1984) Determinants of marital quality in dual-career couples. Fam Relat 33:513–521 87. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, STROBE Initiative (2007) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med 4:e296. doi:10.1371/journal.pmed.0040296 88. Warr P, Cook J, Wall T (1979) Scales for the measurement of some work attitudes and aspects of psychological well-being. J Occ Psych 52:129–148 89. Watson D (1997) Of vets and stress and things. VBJ 20:45–48 90. Welsch BB (1998) Gender differences in job stress, burnout and job satisfaction as mediated by coping style of veterinarians in private equine practice. Dissertation, University of Florida

123

91. Wessells DT (1982) A systems based stress reduction psychological education program for emergency veterinary personnel: development and evaluation. Dissertation, The College of William and Mary in Virginia 92. WHO (2010) World Health Organisation: suicide prevention. http://www.who.int/mental_health/prevention/suicide/suicide prevent/en/. Accessed 11 June 2010 93. Wimberley DL (1991) Work satisfaction, work-related stress, marital/family stress, and spousal support of married veterinarians. Dissertation, Oklahoma State University 94. Wolfgang AP (1988) Job stress in the health professions: a study of physicians, nurses, and pharmacists. Behav Med 14:43–47