A cross-sectional study of mental health and well-being and their associations in the UK veterinary profession Thesis submitted in accordance with the requirements of the Royal College of Veterinary Surgeons for the Diploma of Fellowship by DAVID JAMES BARTRAM May 2009 ABSTRACT A cross-sectional study of mental health and well-being and their associations in the UK veterinary profession David James Bartram Introduction: Veterinary surgeons are at elevated risk of suicide, with a proportional mortality ratio around four times that of the general population and approximately twice that of other healthcare professions. There has been much speculation regarding possible mechanisms underlying increased suicide risk in the profession but little empirical research. This cross-sectional study aims to assess the contribution of mental health and well-being to the elevated risk, through a postal questionnaire survey of a large stratified random sample of veterinary surgeons practising in the UK. Method: A questionnaire was mailed twice to 3200 veterinary surgeons (approximately 20% of the membership of the Royal College of Veterinary Surgeons, excluding those practising overseas or retired). Anxiety and depressive symptoms, alcohol consumption, suicidal ideation, positive mental well-being, perceptions of psychosocial work characteristics, and work-home interaction were assessed using valid and reliable existing instruments. Potential veterinary work-related stressors were assessed using a series of bespoke items developed through focus group input and refined following pre- and pilot- testing. Results: Evaluable questionnaires were returned by 1796 participants, a response rate of 56.1%. The demographic and occupational profile of respondents was fairly representative of the UK veterinary profession. The prevalence of anxiety, depression, and co-morbid anxiety and depression ‘probable cases’ (i.e. HADS sub-scale score ≥ 11) was 26.3% (95% CI: 24.3 to 28.4%), 5.8% (95% CI: 4.8 to 7.0%) and 4.5% (95% CI: 3.6 to 5.6%) respectively. The 12-month prevalence of suicidal thoughts was 21.3% (95% CI: 21.0 to 23.6%). Number of hours worked; making professional mistakes; and the possibility of client complaints or litigation were the main reported contributors to stress. Good clinical outcomes; relationships with colleagues; and intellectual challenge/learning were the greatest sources of satisfaction. Mental health and well-being are associated with a variety of demographic and occupational variables including age, gender, type of work, and employment status. Conclusions: Compared to the general population, veterinary surgeons are estimated to report higher levels of anxiety and depressive symptoms; higher 12-month prevalence of suicidal thoughts; less favourable psychosocial working conditions in relation to demands and managerial support; lower levels of positive mental well- being; and higher levels of negative work-home interaction. They drink more frequently than the general population, but consume less on a typical drinking day and a have a prevalence of daily and weekly binge-drinking that is similar to the general population. The levels of psychological distress reported suggest ready access to and knowledge of lethal means is probably not operating in isolation to increase suicide risk within the profession. The level of alcohol consumption does not appear to be a negative influence on mental health within the profession as a whole. The results are used to propose a portfolio of interventions, for both organisations and individuals, which have the potential to improve mental health and well-being in the veterinary profession. i DECLARATION I do hereby declare that, A cross-sectional study of mental health and well-being and their associations in the UK veterinary profession submitted in part fulfilment of the requirements for the RCVS Diploma of Fellowship by David James Bartram May 2009 has not been submitted for any other degree or comparable qualification and is the result mainly of my own original observations and research and I have not been awarded a degree or diploma by any university or other body in respect of the major part of the work incorporated into this thesis. Candidate’s signature: Date: ii PUBLICATIONS AND CONFERENCE PRESENTATIONS The following publications and conference presentations are based on work incorporated into this thesis: 2008 BARTRAM, D.J. & BALDWIN, D.S. (2008) A cross-sectional study of mental heath and well-being and their associations in the UK veterinary profession. [Oral presentation and abstract, British Cattle Veterinary Association Congress, 14-16 November, 2008. Killarney, Ireland] Cattle Practice [Journal of British Cattle Veterinary Association] 16 (2), 93-94 BARTRAM, D.J. & BALDWIN, D.S. (2008) Mental health and wellbeing survey [Letter]. Veterinary Record 161, 360 BARTRAM, D.J. & BALDWIN, D.S. (2008) Mental health and wellbeing survey [Letter]. Veterinary Record 162, 868 BARTRAM, D.J. & BALDWIN, D.S. (2008) Suicide among veterinary surgeons. [eLetter, 13 Jul 2008] British Journal of Psychiatry. Available at http://bjp.rcpsych.org/cgi/eletters/193/1/73 BARTRAM, D.J. & BALDWIN, D.S. (2008) Veterinary surgeons and suicide: a hypothetical model to explain risk. [Oral presentation and abstract] Proceedings of 12th European Symposium on Suicide and Suicidal Behaviour, 27-30 August, 2008. Glasgow, UK. pp 57-58 BARTRAM, D.J. & BALDWIN, D.S. (2008) Veterinary surgeons and suicide: influences, opportunities and research directions. Veterinary Record 162, 36-40 BARTRAM, D.J., YADEGARFAR, G. & BALDWIN, D.S. (2008) A cross-sectional study of mental heath and well-being and their associations in the UK veterinary profession. [Oral presentation and abstract] Proceedings of ‘Primed and Ready to Go! Developing Mental Health Services through increasing Research Activity’, Hampshire NHS Partnership Trust/ University of Southampton Conference, 1 October, 2008. Eastleigh, UK. p 14 BARTRAM, D.J., YADEGARFAR, G. & BALDWIN, D.S. (2008) Reported alcohol consumption, depressive and anxiety symptoms, and mental well-being among UK veterinary surgeons: cross- sectional questionnaire survey. [Poster presentation at the Summer Meeting of the British Association for Psychopharmacology, 20-23 July, 2008. Harrogate, UK] Journal of Psychopharmacology 22 (5 Abstract Suppl.), A30 iii 2009 BARTRAM, D.J. (2009) A cross-sectional study of mental health and well-being in the UK veterinary profession. [Oral presentation and abstract] University of Southampton MHLS Faculty Postgraduate Conference, 2-3 June, 2009. Southampton, UK. p 19 BARTRAM, D.J. (2009) It shouldn’t happen to a vet. Suicide and mental health in the veterinary profession – do we have a problem? [Oral presentation] British Veterinary Association Congress, 24- 26 September, 2009. Cardiff, UK. BARTRAM, D.J. (2009) The mental health of the UK veterinary profession – how do equine practitioners fare? [Oral presentation and abstract] Handbook of Presentations, 48th British Equine Veterinary Association Congress, 9-12 September, 2009. Birmingham, UK. pp 235-236 BARTRAM, D.J. & BALDWIN, D.S. (in press) Veterinary surgeons and suicide: a structured review of possible influences on increased risk. Veterinary Record BARTRAM, D.J., SINCLAIR, J.M.A. & BALDWIN, D.S. (2009) Alcohol consumption among veterinary surgeons in the UK. Occupational Medicine 59, 323-326 BARTRAM, D.J., SINCLAIR, J.M.A. & BALDWIN, D.S. (in press) Towards improving the mental health and well-being of UK veterinary surgeons. Veterinary Record BARTRAM, D.J., YADEGARFAR, G. & BALDWIN, D.S. (2009) A cross-sectional study of mental heath and well-being and their associations in the UK veterinary profession. Social Psychiatry and Psychiatric Epidemiology, E-pub ahead of print: 18 Mar 2009. doi: 10.1007/s00127-009-0030-8 BARTRAM, D.J., YADEGARFAR, G. & BALDWIN, D.S. (2009) A cross-sectional study of mental heath and well-being in the UK veterinary profession. [Oral presentation and abstract] Proceedings of British Small Animal Veterinary Association 52nd Annual Congress, 2-5 April, 2009. Birmingham, UK. p 372 BARTRAM, D.J., YADEGARFAR, G. SINCLAIR, J.M.A. & BALDWIN, D.S. (2009) Associations between alcohol consumption and psychosocial working conditions among UK veterinary surgeons: cross-sectional questionnaire survey. [Poster presentation at the Summer Meeting of the British Association for Psychopharmacology, 26-29 July, 2009. Oxford, UK] Journal of Psychopharmacology 23 (6 Abstract Suppl.), A36 BARTRAM, D.J., YADEGARFAR, G. & BALDWIN, D.S. (2009) Psychosocial working conditions and work-related stressors among UK veterinary surgeons. Occupational Medicine 59, 334-341 iv ACKNOWLEDGEMENTS I gratefully thank and acknowledge Dr David S. Baldwin1 for his enthusiastic and supportive academic supervision and generosity with his time throughout this initiative and Dr Ghasem Yadegarfar2 for his initial guidance and coaching with some of the statistical analyses. Veterinary Business Development Ltd., publisher of Veterinary Times, provided use of the Vetfile® database as the sampling frame, printed and posted the questionnaires and covering letters, and supplied reply-paid envelopes free of charge. BUPA Giving provided financial support for the project. The study would not have been possible without the support of the participating veterinary surgeons throughout the UK who collectively invested over 600 hours of their time in completing and returning the questionnaires. I offer the assurance of my best efforts