Introduction

The COVID-19 pandemic has impacted the physical and mental health of medical professionals around the globe.^1–7 Veterinary professionals, like other health providers, have coped with prepandemic challenges, such as high risk of occupational stress, burnout, poor psychological well-being, and suicidal ideation.^8–13 The compounding impact of prepandemic stressors (eg, debt-to-income ratio, work demand, and professional isolation) with pandemic-related stressors (eg, limited social outlets, health-related anxiety, and redesign of workplace procedures) have led to health concerns for this largely resilient group of professionals.^5,8,14–18

Some evidence suggests that veterinarians experience higher rates of stress, anxiety, depression, and suicide compared with the general population.^14,15,17,19 These rates might be explained by the profession-specific stressors associated with practicing veterinary medicine found in the literature, such as mental health stigma, workload, financial stress, fear of complaints, challenging client interactions, access to lethal means, exposure to death, and euthanasia attitudes.^{10,11,15–18,20} In response, the mental health of veterinarians has become a growing area of prioritization over the past decades, and the accessibility of support is increasing.^19,21–23 The AVMA steadily adds well-being resources and information to its website,²⁴ and veterinary social workers and other behavioral health providers are becoming available for support, consultation, and education on topics related to ethics, client communication, and stress management. Indeed, these topics are increasingly being incorporated into veterinary curricula, and many colleges of veterinary medicine offer tailored services to prepare students to work in high-stress environments.^25–27

Despite the prioritization of professional wellness and distribution of resources, veterinarians appear to be ambivalent about service utilization for their mental health, even when it is indicated. Prior to the pandemic, less than half of veterinarians with high levels of psychological distress reported receiving treatment for their mental health.¹³ In addition, only a small number of veterinarians experiencing burnout or compassion fatigue sought professional help for these concerns.²⁸ Historically, veterinarians with significant psychological distress have struggled to engage with the web-based programming provided by their professional organizations and have cited accessibility and stigma as barriers toward receiving mental health treatment.¹³ The current state of service utilization among veterinarians, however, is less clear in our current COVID-19 landscape. Based on the barriers reported to date (ie, accessibility and stigma), it is possible that veterinarians continue to underutilize mental health services even during times of increased and compounded stress.

Veterinarians’ perceptions of mental health care, and the incentives and barriers associated with receiving services, have yet to be fully understood at this time when resources are becoming more widely accessible via web-based platforms. Considering career stage in addition to age provides a more complete perspective on the factors associated with mental health service utilization among veterinarians. Work-related factors associated with career stage have been tied to mental health and resilience. That is, more experienced veterinarians with higher annual incomes report lower burnout and secondary traumatic stress than those with less experience and lower incomes.²¹ Further, during COVID-19, veterinarians’ stress about pandemic risk has varied by career stage. Older age and having a leadership role are associated with decreased perceived pandemic risk, increased confidence, and greater levels of job-related efficacy.²⁹

In sum, prior evidence supports the assertion that there are generational and career stage differences in distress, mental health needs, and perceptions of pandemic risk and stressors. It is unclear, however, how veterinarians in different career stages perceive mental health treatment as well as associated incentives and barriers, especially during times of increased stress. Considering these career stage differences during COVID-19 could not only provide insight into patterns of service utilization during times of compounded stress but also further explain why many veterinarians are not turning to behavioral health providers and resources in general. As such, the purpose of the present study was to explore veterinarians’ mental health symptom burden during COVID-19 and identify differences in symptom burden, social support, help seeking, and incentives and barriers associated with receiving help across career stages. On the basis of research to date, several hypotheses were proposed. First, given the level of prepandemic mental health concerns among veterinarians, we hypothesized that veterinarians would report at least mild symptom burden during COVID-19. Second, following prepandemic trends, we hypothesized that veterinarians would continue to underutilize mental health resources despite the stressors brought on by the pandemic. Finally, we expected there would be career stage differences in reported symptom burden, social support, and help seeking for mental health concerns.

Materials and Methods

The Potomac Regional Veterinary Coping, Resilience, and Challenges (CRC) survey was developed and administered as previously described.³⁰ Briefly, the survey was designed and disseminated by a transdisciplinary team of researchers, administrators, veterinarians, and behavioral health providers. The survey contained both validated psychosocial measures and individual items developed by the authors to assess the impact of COVID-19 on veterinarians and veterinary practices. This research was approved by the Institutional Review Boards of participating institutions. Sampling procedures included convenience and snowball sampling. Information regarding the CRC survey was distributed to veterinarians through regional veterinary association listservs, word of mouth, social media, and a university web page dedicated to survey dissemination. Survey data were collected via an online platform (Qualtrics Survey Software; Qualtrics XM) and took participants approximately 30 to 45 minutes to complete. Data were collected from June 4 to September 8, 2021.

Results

The sample consisted of veterinarians (n = 266) who indicated their primary role was clinical only (232), administrative with some clinical responsibilities (11), nonclinical (19), and other (4) on the CRC survey. Veterinarians in practice reported working in general practice (n = 176), specialty practice (28), or “other” (29). Participants also reported their current and primary workplace as either small-animal practice (n = 183), food-animal practice (2), equine practice (11), mixed animal practice (20), shelter practice (6), or “other” (44). In terms of their connectedness with others, 81.6% (214/262) veterinarians reported working with other veterinarians, while 17.1% (45/262) did not have other veterinarians in their workplace. The early-career category consisted of veterinarians with up to 4 years of experience (26/262 [9.9%]), midcareer included those with 5 to 19 years of experience (130/262 [49.6%]), and late career had 20 or more years of experience (106/262 [40.4%]). As was expected, preliminary analyses revealed significant differences in ages between all 3 career stage groups. Demographic information on gender, age, and race and ethnicity was identified (Table 1). All validated scales utilized in this study held up well in this sample with Cronbach α’s ranging from good to excellent (PHQ-4 = 0.89; MPSS = 0.95; MHSAS = 0.92; and MHSIS = 0.96).

Results from descriptive analyses indicated that data on variables of interest were skewed, thus violating the assumption of normal distribution. In addition, the career stage groupings were uneven, with fewer respondents reporting from the early-career group (n = 26) than the midcareer (130) and late-career (106) groups. However, Levene tests indicated that data were homogenous across career stage groups. Regarding normality, F tests often remain robust when values of skewness and kurtosis fall between –1 and 1.³⁵ In these data, measures of skewness and kurtosis for all variables except MPSS stayed within the –1 to 1 range. The MPSS had a skewness statistic of –1.03, which fell only slightly outside of the acceptable range. Based on the robustness of the F test in instances of skewness, the ANOVA test was utilized. An α level of 0.05 was used as the cutoff for significance.

Discussion

Results of the present study revealed that, despite reports of symptom burden and the added stressors related to COVID-19, professional mental health services and organized peer support groups continue to be underutilized. As anticipated, early- and midcareer veterinarians experienced higher anxiety and depression than their late-career counterparts. There are several possible explanations for this finding. First, the financial, professional, and social challenges of beginning and maintaining a career, perhaps exacerbated during COVID-19, might have contributed to increased symptoms.¹³ Indeed, veterinarians who graduated from veterinary programs during the first 2 years of the pandemic completed their curricula under novel circumstances. These cohorts obtained less practice with in-person client interactions and were tasked with learning to navigate remote forms of professional communication. They routinely facilitated sensitive procedures, such as humane euthanasia, from a distance to mitigate potential COVID-19 exposure. Notably, these cohorts were also more likely than those previous to be physically separated from social supports. These training and practice changes likely compounded any usual stressors of starting a veterinary career for these new professionals. Second, veterinarians in both early-career and midcareer stages might be more likely to take on more responsibilities at work (eg, moving into managerial roles) and at home (eg, taking care of young children or other family members) than their early-career and late-career colleagues. These shifts require veterinary professionals to balance growing and competing priorities. COVID-19 placed additional burdens on veterinarians who might have already struggled to attend to both personal and professional obligations.

Our analyses revealed interesting findings related to mental health help seeking across career stages. There were no group differences on help-seeking attitudes; veterinarians in all career stages reported similar outlooks on seeking help for mental health concerns. There were, however, significant group differences on help-seeking intentions. Specifically, midcareer veterinarians reported greater intentions to seek help if they had mental health concerns than late-career veterinarians. In addition, differences between early- and midcareer veterinarians approached statistical significance, indicating that midcareer veterinarians might be more inclined to seek help than their early-career colleagues. Therefore, despite all groups having similar attitudes toward mental health help seeking, late-career and possibly early-career veterinarians reported lower intentions to reach out for professional help with their mental health when needed. One explanation might be that the higher levels of help-seeking intentions among midcareer veterinarians, compared with those in late career, mirrors the efforts to destigmatize mental health issues in the veterinary profession. Midcareer veterinarians entered the field during times when resources were becoming more available in the colleges of veterinary medicine and training orgnaizations.^25–27 If destigmatization, however, was indeed responsible for these differences in help-seeking intentions, we might ask why early-career veterinarians did not report significantly greater help-seeking intentions than the other groups. After all, this was the cohort that likely had the most exposure to mental health and wellness programming in their training. Another explanation, therefore, is warranted to understand why group differences were found on help-seeking intentions but not attitudes. While exposure to wellness resources over the past decades have perhaps shaped personal attitudes toward mental health services across career stages, this exposure might not be sufficiently addressing the barriers that impede intentions to seek care, particularly among early- and late-career veterinarians. In sum, the differences found in mental health help-seeking intentions do not seem to be attributable simply to mental health need (symptom burden) and instead could be due to perceived incentives and barriers associated with seeking support.

While our findings on incentives and barriers toward seeking mental health care did not fully elucidate identified career stage differences in help-seeking intentions, they do provide some meaningful additions to the growing body of literature on service utilization. In prior survey research, accessibility has been cited as a primary barrier for mental health service utilization before COVID-19.¹³ Our results from during the pandemic indicate that accessibility issues, such as availability of resources and scheduling, may have been less of a barrier than in the past. Many veterinarians cited their own time limitations as being a primary barrier as opposed to behavioral health providers’ accessibility. In their free responses, some veterinarians punctuated concerns about the quality of providers and treatment as another clear barrier for seeking care. These findings highlight the multitude of factors that contribute to veterinarians’ decisions to utilize mental health services.

This study had several limitations. First, as convenience and snowball sampling techniques were used, we likely encountered bias due to participant self-selection. As such, our results may only be representative of respondents who were engaged and interested in discussions related to mental health and service utilization. It is noteworthy, however, that despite current limitations on time and resources due to the pandemic, hundreds of veterinarians working in the Potomac region were willing to donate their time and energy to participate. Second, while symptom burden was examined through a validated tool, results from screeners like the PHQ-4 cannot provide a comprehensive perspective on the state of mental health functioning among respondents. Diagnostic tools designed for assessment of depression and anxiety are warranted to obtain more robust mental health information in future studies.

Several recommendations for future research have emerged from our findings. Given that mental health help-seeking attitudes were generally positive in our sample, we suggest a call to action to thoroughly explore incentives and barriers associated with intentions to seek help when symptom burden is high. In other words, our results on help-seeking attitudes revealed that mental health care could be becoming more accepted across career stages, but this might not be translating to intentions to actually seek help in expected ways. With the rise of telehealth platforms and options for virtual counseling, traditional accessibility issues are becoming less of a barrier for resourced populations.

On the basis of preliminary qualitative data on barriers gathered in this study, it might be that a stronger working relationship between the veterinary and mental health professions must continue to be built to garner trust. As some respondents suggested, the unique working conditions in the veterinary profession require any close confidant to have a level of understanding and expertise that some behavioral health providers might not have (or are presumed not to have). This may be why veterinarians are turning to social supports instead of professional behavioral health providers.⁸ Therefore, 1 explanation for the low service utilization reported in prior studies is that veterinarians turn to their immediate social networks for care and support in times of distress.¹⁸ This approach might indeed be adaptive among veterinarians when considering their concerns about stigma. Furthermore, during the pandemic, social support has proven to be protective against mental health symptoms and buffered the impact of these symptoms in workplace performance.³ Another explanation for turning to immediate social networks, perhaps in lieu of behavioral health providers, might be veterinarians’ perceptions about the utility of mental health services. The perception of the need and utility for such services may be generational. Younger veterinarians (those presumed to be earlier in their career) are more likely to experience serious levels of mental health distress compared to their peers in the general population as well as their fellow veterinarians ages 45 and older.¹³ As such, it might be that younger cohorts of veterinarians have a greater need for seeking professional help for psychological distress. It remains unclear from our preliminary work, however, whether they are definitively doing so in response to this increased distress and doing so more than their older colleagues.

The veterinary profession has yet to elucidate what factors serve to increase and diminish perceived confidence in behavioral health providers and their services. Future research could better identify the nature of such barriers; whether they are a result of the logistical, psychological, and/or social challenges veterinarians face; and how they might be overcome to improve service utilization when veterinarians are burdened by mental health concerns.