Introduction

Suicide is the second leading cause of death in the United States in 10- to 34-year-olds¹ with veterinarians having a higher risk of suicide than the general public.^2–4 The National Institute of Mental Health lists preexisting psychiatric disorders (eg, depression, anxiety, substance misuse, and others) and access to lethal means as risk factors for suicide⁵; additional studies also include exposure to chronic stress as a major risk factor.^6,7 Two-thirds of veterinarians have experienced depression, burnout, anxiety, or panic attacks.⁸ Due to licensing, veterinarians have easier access to controlled drugs, and use of pharmaceuticals has been one of the more commonly cited methods of suicide in the veterinary population.^2,9 Tomasi et al² also noted that female veterinarians were more likely to die by use of pharmaceuticals, while male veterinarians were more likely to die by use of firearms. Lastly, poor work-life balance, social isolation, compassion or empathy fatigue related to the stress of recurring euthanasia of their patients, burden transfer (ie, stressful client behavior transferred to the veterinarian), and educational debt together produce some of the most frequently cited forms of chronic stress in the field of veterinary medicine.^9–12

If appropriate adaptive coping mechanisms have not been developed prior to starting professional practice, such occupational triggers can strain an individual’s window of tolerance and propel them into an anxious or depressive state.¹³ A cross-sectional study of 11,627 US veterinarians reported that 1 in 11 had serious psychological distress and 1 in 6 experienced suicidal ideations since graduating veterinary school.¹⁰ High rates of anxiety and depression also have been reported in Doctor of Veterinary Medicine (DVM) students.^14–16 Early mental health interventions are important for addressing mental health risk factors.¹⁷ Therefore, to counteract the negative mental health outcomes observed in the veterinary profession, preventative mental health interventions must begin earlier with one point of entry being at the start of students’ veterinary education.

Beyond receiving professional treatment for a mental health condition, sustained behavior change is key to the continued prevention and treatment of most psychiatric conditions.¹³ Behavior change initiatives are challenging when the onus is placed solely on the individual. The Social Ecological Model theorizes that for sustainable change to occur, the individual’s environmental culture (ie, the policies and procedures that influence the individual) must also change.¹⁸ This theory is similar to The National Institute for Occupational Safety and Health’s (NIOSH) Hierarchy of Controls Applied to the NIOSH Total Work Health model, which emphasizes that organizational-level interventions are key for protecting worker safety, health, and well-being when a working condition hazard cannot be fully eliminated.¹⁹ Consequently, colleges of veterinary medicine must cultivate environments and build cultures that are conducive to mental health promotion via appropriate health-enhancing policies, programs, and practices.

Findings from prior research have shown that a cognitive-behavioral skills building program (MINDSTRONG; The Ohio State University) can decrease depression, anxiety, stress, and suicidal ideation, and improve healthy lifestyle beliefs and lifestyle behaviors in undergraduate and graduate professional students.^20–22 The program reviewed was based on cognitive behavioral theory, 7 weeks in length, and focused on building mental health resiliency and enhanced emotional regulation in children, adolescents, and young adults.²⁰ While veterinary industry leaders support wellness programming^23,24 and numerous US veterinary schools have implemented mental health and wellbeing strategies for their students, a paucity of experimental research exists in terms of the magnitude in which such programing can improve the mental health outcomes and healthy lifestyle behaviors for DVM students. Therefore, the purpose of this pre-and postcourse survey study was to evaluate the effects of a cognitive-behavioral skills building MINDSTRONG program on the mental health outcomes and healthy lifestyle beliefs and behaviors of DVM students.

Materials and Methods

A pre-experimental pre- and post-test design was used with first year DVM students from a large public land-grant Midwest university. All 171 incoming DVM students (class of 2024) were required to complete the cognitive behavioral skills building program (MINDSTRONG; The Ohio State University) virtually over the summer prior to starting their 2020 school year (ie, before academic coursework began). The university’s Institutional Review Board approved the study and students were given the option to consent to the study portion of the program.

Before starting the program, participants completed a baseline survey through an electronic data capture software (REDCap version 9.1.0; Vanderbilt University). The Personal Wellness Assessment (PWA) was comprised of demographics, the Patient Health Questionnaire-9 (PHQ-9),²⁵ the Generalized Anxiety Disorder-7 (GAD-7),²⁶ the Brief Inventory of Perceived Stress (BIPS),²⁷ the Healthy Lifestyle Beliefs Scale,²⁸ and the Healthy Lifestyle Behaviors Scale.²⁹ After completing the program (ie, 7 weeks after taking the baseline PWA), participants retook the PWA to establish the MINDSTRONG program’s impact on their mental health and healthy lifestyle beliefs/behaviors.

Measures

PHQ-9—The PHQ-9,²⁵ a 9-item instrument, uses a summative rating scale to assess depressive symptoms. Participants are asked to evaluate their depressive symptoms for the previous 2 weeks on a scale of 0 (not at all) to 3 (nearly every day). Higher scores indicate higher levels of depressive symptoms. The psychometric properties of the instrument have been well established in a variety of populations and settings, and a recent meta-analysis reported that it has good sensitivity (0.88) and specificity (0.88) for detecting major depressive disorders.³⁰ Cronbach’s α is a measure of internal consistency, that is, how closely related a set of items are as a group and is considered to be a measure of scale reliability. In prior studies, the Cronbach’s α for this scale were above 0.80.^20,31

Of particular importance for this study, was student responses to question 9, Thoughts that you would be better off dead or hurting yourself in some way, as this is considered a warning sign of suicide. Participants who had a positive response to question 9 or students who screened positive for moderate to severe depression received follow-up referrals to university counseling services and hotline information.

GAD-7—The GAD-7,²⁶ a 7-item instrument, uses a summative rating scale to assess an individual’s anxiety level. Participants rank their anxiety for the previous 2 weeks on a scale of 0 (not at all) to 3 (nearly every day), thus scores range from 0 to 21 (≥ 5 = mild anxiety, ≥ 10 = moderate anxiety, and ≥ 15 = severe anxiety). The scale has good sensitivity (0.89) and specificity (0.82) for GAD. Cronbach’s α in prior studies are at or above 0.88.^20,31

BIPS scale—The BIPS,²⁶ a 9-item instrument, assesses levels and categories of stress (lack of control, being pushed, and conflict and imposition). Participants use a 5-point Likert scale ranging from 0 (never) to 4 (very often) to assess their perceived stress level, thus scores range from 0 to 36. A higher score indicates greater stress. BIPS has established content validity, with Cronbach’s α above 0.85.²⁷

Healthy Lifestyle Beliefs Scale—The Healthy Lifestyle Beliefs Scale, a 16-item instrument, was adapted from other belief scales by the first author.²⁸ This scale assesses beliefs about various components of maintaining a healthy lifestyle (eg, “I believe that I can be more active” and “I am sure that I will do what is best to lead a healthy life”). Participants use a Likert scale that ranges from 1 (strongly disagree) to 5 (strongly agree) to respond to each item, thus final scores range from 16 to 80. A higher score indicates a higher level of healthy lifestyle beliefs. This scale has established content validity; Cronbach’s α have been above 0.80 in prior studies.^28,31

Healthy Lifestyle Behaviors Scale—The Healthy Lifestyle Behaviors Scale,²⁹ a 15-item scale, assesses healthy lifestyle behaviors (eg, “I exercise regularly,” “I talk about my worries or stressors,” and “I made choices that lead to a healthy lifestyle”). Participants use a Likert type scale that ranges from 1 (rarely or none of the time) to 5 (most or all of the time) to respond to the scale items, thus final scores range from 15 to 75. A higher score indicates a higher level of healthy lifestyle behaviors. This scale has established content validity; Cronbach’s α have consistently been above 0.78 in prior studies.^31,32

The intervention program

The MINDSTRONG program utilized is a manualized seven-session cognitive-behavioral skills building program, based on cognitive-behavioral therapy, led by a trained program facilitator. Prior to delivering the MINDSTRONG program, facilitators must complete a 4-hour training workshop that describes the program’s evidence, session content, and interventions. For participants, one 45-minute virtual session is provided each week over the course of 7 weeks (Supplementary Table S1). Throughout the MINDSTRONG program, students practice turning automatic negative thoughts into positive ones to lessen stress and improve mood. Students also are taught how to regulate emotions, positively cope with stressors, and problem solve. Each session is followed by skills building activities that help students to put the content that they are learning into practice.

Data analysis

Only students (n = 62) who consented to having their data collected as part of this study, completed the baseline survey, and completed the postprogram survey were included in the analyses. Overall sample characteristics were analyzed via descriptive statistics (eg, gender and race/ethnicity). Paired t tests were used to assess changes over time in healthy lifestyle beliefs, healthy lifestyle behaviors, depression, anxiety and stress. Cohen’s d was used to determine effect sizes. Cutoffs for the effect sizes were 0.2 (small), 0.5 (medium), and 0.8 (large). All statistical analyses were performed using commercially available software (Stata version 14.2; StataCorp).

Results

Of the 171 DVM students who were required to go through the MINDSTRONG program, 62 provided consent to participate in this study and completed both the baseline and post survey. Participants who received referrals to counseling services were included in the analysis; and separate segmented analyses were conducted specifically among participants with moderate to severe depression and suicidal ideation, respectively. The majority of students were female (80.65%) and Non-Hispanic White (69.4%). The second most commonly reported race/ethnicity was Asian/Pacific Islander (12.9%). These sample demographics were similar to the class of 2024 statistics from the college (78% female, 65% Non-Hispanic White, and 35% Racial and Ethnic Diversity students; unpublished data from the college of veterinary medicine’s dean). A full listing of the participant demographics are listed (Table 1).

At baseline (prior to starting the MINDSTRONG program), 20 students screened positive for mild to moderate depression (32.3%) and 22 (33.9%) for mild to moderate anxiety.

Approximately two-thirds of the students screened negative for symptoms of depression (n = 42 [67.7%]) or anxiety (39 [62.9%]). Four students (6.5%) indicated having thoughts that they would be better off dead or hurting themselves in some way several days per week or more. The mean ± SD BIPS score was 15.65 ± 6.07, suggesting that students were experiencing mild to moderate stress levels. Students reported strong healthy lifestyle beliefs (mean ± SD, 65.4 ± 6.4), but had lower healthy lifestyle behaviors (mean ± SD, 54.7 ± 6.46). Distribution of DVM students’ mental health attributes and healthy lifestyle beliefs/behaviors at baseline and postprogram are summarized (Table 2).

After the MINDSTRONG program (7 weeks after the baseline survey), scores for anxiety improved with a small positive effect (P = 0.05; Cohen’s d = –0.3; Figure 1). Scores for depression (on the PHQ-9) and stress (on the BIPS) did not decrease significantly in the total group. However, significant improvements were found when the student population was segmented by level of depressive and anxiety symptoms. For example, students with mild depression (PHQ-9 score ≥ 5) had a significant decrease in anxiety with a medium positive effect (P = 0.05; Cohen’s d = –0.5; Figure 2). Students with moderate depression (PHQ-9 score ≥ 10) had significant decreases in both anxiety and depression with large positive effects (P = 0.04; Cohen’s d = –0.96; P = 0.03; Cohen’s d = –1.10; Figure 3). A similar trend was observed with students who had moderate or severe anxiety (GAD-7 score ≥ 10; Figure 4) who had had significant decreases in depressive symptoms (P = 0.03; Cohen’s d = –0.69) and anxiety (P = 0.01; Cohen’s d = –0.80) with moderate positive effects for the intervention. Healthy Lifestyle Beliefs and Healthy Lifestyle Behaviors (P = 0.01; Cohen’s d = 0.3) scores improved significantly with small to medium positive effects (P = 0.03; Cohen’s d = 0.3; P = 0.01; Cohen’s d = 0.3) regardless of the mental health starting points observed at baseline.

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Effects of the Cognitive Behavioral Skills Building Program (MINDSTRONG; The Ohio State University) on Doctor of Veterinary Medicine (DVM) Students’ Outcomes (n = 62). Values of P < 0.05 were considered significant.

Citation: Journal of the American Veterinary Medical Association 260, 7; 10.2460/javma.21.03.0142

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Effects of the Cognitive Behavioral Skills Building Program (MINDSTRONG) on the Outcomes of DVM Students’ with Mild Depression (n = 20). Mild depression = Patient Health Questionnaire-9 (PHQ-9) score ≥ 5. Values of P < 0.05 were considered significant.

Citation: Journal of the American Veterinary Medical Association 260, 7; 10.2460/javma.21.03.0142

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Effects of the Cognitive Behavioral Skills Building Program (MINDSTRONG) on the Outcomes of DVM Students with Moderate Depression at Baseline (n = 7). Moderate depression = PHQ-9 score ≥ 10. Values of P < 0.05 were considered significant.

Citation: Journal of the American Veterinary Medical Association 260, 7; 10.2460/javma.21.03.0142

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Effects of the Cognitive Behavioral Skills Building Program (MINDSTRONG) on the Outcomes of DVM Students with Moderate or Severe Anxiety at Baseline (n = 13). Moderate or severe anxiety = Generalized Anxiety Disorder-7 score ≥ 10. Values of P < 0.05 were considered significant.

Citation: Journal of the American Veterinary Medical Association 260, 7; 10.2460/javma.21.03.0142

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Given the small sample of students who at baseline selected that they were having thoughts of being better off dead or hurting themselves in some way, inferential analysis was not performed. However, of the 4 students who had these suicidal ideations, only 1 still indicated having these thoughts postprogram.

Discussion

This study’s findings support the positive effects that the cognitive behavioral skills building intervention program, MINDSTRONG, had in decreasing depressive and anxiety symptoms as well as improving healthy lifestyle beliefs and behaviors in DVM students. The most significant improvements were observed in students who had elevated depression and anxiety at baseline. These findings are similar to prior intervention research that used the same program entitled COPE (Creating Opportunities for Personal Empowerment).^20–22 Additionally, after the MINDSTRONG program, the majority of participants who had indicated thoughts of self-harm no longer reported feeling that way. A cluster randomized control trial with adolescents determined that the effects of utilized program can be sustained for up to 12 months post intervention.³³ Thus, alluding to a potential similar effect in the current study’s sample population. However, longitudinal studies would need to be performed with this specific emerging adult population to confirm such a carry over.

At baseline, approximately one-third of students screened positive for mild to moderate depression and anxiety. Previous research also has reported similar rates in the veterinary student population.¹⁵ In this study, 4 students (6.4%) reported that they would be better off dead or hurting themselves in some way. The rates at which these thoughts occurred were similar to other reported research (6.25% to 6.5% vs 30%).¹⁵ This data supports the need to screen students for depression and suicidal ideation as they begin their academic programs and provide interventions and/or referral to those in need.

The MINDSTRONG program used was rooted in cognitive behavioral therapy (CBT), which is considered to be the gold standard evidence-based treatment for mild to moderate depression and anxiety.³⁴ CBT also can decrease self-harm.³⁵ Traditionally, CBT is provided by a mental health professional, but due to shortages of mental health professionals, many in need of CBT are unable to access it.³⁶ Veterinary students tend to be high-seeking when it comes to pursuing counseling services,^15,37 however, at the national level, expansion of such services have not kept up with demand.^38,39 Cognitive behavioral skills building programs such as the one used in this study address this issue by providing an evidence-based intervention that can be delivered by nonpsychiatric mental health professionals. It should be noted that the college at which this study took place has two full time mental health counselors for their students (roughly 648), a ratio better than the recommended minimum (1 counselor for every 1,000 to 1,500 students).⁴⁰ Arguments have been made that staffing ratios do not provide appropriate guidance as they do not account for the variation in student utilization rates or clinical outcomes like treatment dosages and distress change.⁴¹ Nonetheless, this program is not meant to replace counseling services; rather, it aims to be used as a preventive and early intervention for those suffering from mild to moderate depression and anxiety, an approach recently recognized by the National Academies of Sciences, Engineering, and Medicine³⁹ as vital for improving student population health and reducing professional burnout.

Students had improvements in their healthy lifestyle beliefs and behaviors after completing the MINDSTRONG program. Increased sedentary behavior and consumption of high-calorie/low-nutrient foods can negatively impact one’s mental and physical health.⁴² Furthermore, healthy lifestyle behaviors are negatively correlated with measures of depression and anxiety.^16,43–45 Therefore, improvements in depression and anxiety can result in healthier lifestyle behaviors.

Veterinary school is rigorous and demanding. Competition to succeed is high, while course work, clinical work, and lack of sleep can feel ever growing and overwhelming.¹⁴ One program alone cannot mitigate all of the stressful factors that students deem to be out of their control, like organizational culture, practices, and policies, but it can build mental resiliency and provide skills to better cope with various stressors. System level contributors play a substantial role in a students’ ability to make healthy lifestyle choices,⁴⁶ and when such conditions cannot be fully eliminated, organizational-level interventions are needed.¹⁹ Consequently, veterinary schools must also establish and sustain cultures focused on overall well-being, based upon the various dimensions of well-being. Addressing organizational culture includes having institutional leaders speak to the importance of creating and sustaining a wellness culture; training faculty and staff on how to create inclusive and healthy learning environments and how those are included in formal and informal education and training; and ensuring that leave of absence policies accommodate students with mental health disorders.³⁹

Limitations of this study include selection bias, the inability to generalize the findings to a larger population of DVM students as the sample was one of convenience, and the influence of students potentially receiving counseling services outside of the program. Lack of an attention control arm also is a limitation. Since no data was available for the students who did not participate in the pre-and postsurveys, it is unclear if participants were more or less likely than non-participants to have underlying mental illness, or to respond/not respond to the program. The sample size was small, from 1 institution, and follow-up data was only provided once (after completion of the program). While the sample size was small, the demographics were similar to those posted by college. Larger multisite studies with longer follow-up periods are needed to determine the short and long-term impact of the specific program used in this study. Students who reported thoughts of suicidal ideation or who screened positive for moderate to severe depression were referred to university counseling services. It is not known how many of these students followed through with their referrals, but if counseling services were obtained this may have influenced study outcomes. However, one of the goals of the MINDSTRONG program is to refer students’ with substantial mental health concerns to student counseling services to ensure they receive more advance care. Lastly, it should be noted that the MINDSTRONG program was provided virtually and during the coronavirus-2019 pandemic. Therefore, it is unknown if the results would have differed under other circumstances. Strengths of this study include use of a cognitive behavioral skills building program based on a strong theoretical framework to improve the mental health of DVM students.

A paradigm shift from crisis intervention to prevention is required for making sustained change in the veterinary mental health epidemic. A substantial number of DVM students are entering their tertiary schooling with pre-existing mental health issues that can be exacerbated by the rigors and stressors of their academic environment and the culture of the institution, including things related to how welcome, comfortable and respected they feel and do they feel the culture is one of inclusion, caring and belonging. Poor coping mechanisms formed during this time have the potential to carry over into their professional career. Therefore, veterinary schools must create and continually evaluate and enhance wellness cultures and teach students how to cope with stress and effectively regulate their emotions through evidence-based programs. Veterinary schools should consider cognitive behavioral skills building programs as 1 element in a comprehensive and integrated health and wellbeing program. Teaching students cognitive-behavioral and coping skills has the potential to decrease rates of depression, anxiety, and suicidal ideation and improve healthy lifestyle behaviors and beliefs during school and ultimately throughout their professional careers.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org