Discharge Notes columnist Dr. Andy Roark is a practicing veterinarian, international speaker and author. He founded the Uncharted Veterinary Conference. His Facebook page, podcast, website and YouTube show reach millions of people every month. Dr. Roark is a three-time winner of the NAVC Practice Management Speaker of the Year Award. Learn more at drandyroark.comRead Articles Written by Andy Roark
Suicide in veterinary medicine is too big of a problem to ignore. At this point, almost all of us have stories of practice owners across town, technicians on weekend shifts and veterinarians we went to school with ending their lives. That’s a lot of loss to accept in any profession, much less one known for compassion and puppy breath. The time has come to push back against this tragic trend.
According to a recently reported study from Auburn University and the U.S. Centers for Disease Control and Prevention, male veterinarians were 1.6 times more likely than the general population to die by suicide and female veterinarians (the growing majority of our profession) 2.4 times more likely.
Suicide in support staff members is prevalent as well. The study showed a suicide rate five times higher among male technicians and technologists and 2.3 times greater among female technicians and technologists. Support staff face many of the same challenges and burdens as veterinarians do, so ignoring their experiences and mental health needs would seem irresponsible.
DVMs are undoubtedly not the only people at risk. The problem affects our entire professional sphere. The causes appear to be multifactorial. Commonly cited stressors include high student debt, a poor work-life balance, low pay, work overload and compassion fatigue.
Suicide is multidimensional and hyperindividualistic, and it requires a multimodal approach to prevention. We can get involved upstream (policy and advocacy), midstream (communications and well-being training) and downstream (disrupting the actual suicide process). Action needs to be taken at every level to turn the tide.
Reducing suicide in veterinary medicine might seem like an uphill battle — and it is. Remembering that the problem must be attacked on multiple fronts, individuals and veterinary clinics can begin to effect change by taking immediate specific steps.
Let me tell you about two programs that clinics should consider today:
1. Four-Eyes Lethal Drug Restriction
The first step is to limit access to the drugs most commonly used in suicides. According to an earlier CDC report, two-thirds of female veterinarians who died by suicide and one-third of male veterinarians used “poison.” The CDC could not report how much “poison” was made up of euthanasia drugs but did indicate it was “a substantial part.”
One way to bring those numbers down is to control access to lethal drugs such that they may be reached quickly when needed but only when two people (“four eyes”) are present. This approach is the norm in human health care, where two people are required both to access controlled drugs and administer them. Of course, veterinarians routinely work alone at some practices, so this step would not be possible, but at most other clinics, a four-eyes approach would be both practical and doable.
The argument for restricting access to lethal drugs has two tenets:
- Suicide attempts are often made impulsively. Indeed, some individuals plan for suicide, prepare over an extended period and act only after careful forethought. But research shows that kind of planning is the exception, not the rule. According to a 2016 study published in Psychiatry Investigation, a large percentage of suicide attempts are impulsive. Interviews with survivors have shown that two-thirds of suicide attempts are contemplated for less than an hour and almost half for no more than 10 minutes.
- Contrary to popular belief, the Harvard School of Public Health reported, people who attempt suicide and survive are unlikely to die by suicide at a later date. This means that if periods of high suicide risk are relatively short (as these figures suggest), and if repeated suicide attempts are rare, then restricting access to the method by which a person intends to end his or her life might disrupt the suicidal process and increase the likelihood of survival.
Veterinary professionals have access to, knowledge of and comfort with lethal medications. We are routinely called upon to justify the use of lethal drugs to end the lives of suffering patients. We counsel grieving pet owners that euthanasia is a humane and compassionate path to end pain. We are trained in the pharmacokinetics of the medications and their proper dosing and administration.
Thus, it is not hard to understand why veterinary professionals seeking to die by suicide often find pharmaceutical poisoning to be acceptable and cognitively available. Anyone who works in or visits multiple veterinary clinics can attest to the wide variation in drug control and safety. “Secret” keys that every staff member knows about, drug box locks that stay unlocked and even bottles of controlled drugs sitting on countertops are far more common than they should be.
In an informal survey of over 8,000 veterinary professionals conducted on my website, 71% of respondents said they could access controlled drugs in their clinic. This included 92% of veterinarians, 74% of managers, 64% of technicians/assistants, 38% of front desk staff and 25% of kennel staff.
- Veterinary professionals have a high suicide rate compared with the general population and often face a variety of emotional stressors in their daily lives.
- Research suggests that, for many, the suicide decision is made impulsively and periods of high immediate suicide risk might be short.
- Veterinary professionals are technically knowledgeable about the veterinary medications that can be used for suicide.
- Veterinary professionals routinely discuss and justify the ending of lives (using lethal medications) as an acceptable and even compassionate alternative to suffering.
- A high percentage of veterinary professionals can privately access lethal medications in their practice.
Restricting access to lethal medications in the hope of disrupting the suicide process represents a key piece of any multimodal approach to suicide prevention. And it’s a piece that works well together with any other efforts, including mental health support.
How to Implement a Four-Eyes Program
Most clinics can quickly and inexpensively start a drug-restriction program. The goal is to create a work environment where potentially lethal drugs can be accessed quickly for veterinary work, but only when two individuals are present. Some clinics use the two-lock system. They give veterinarians the keys to one lock and technicians or managers the keys to the other. The rationale for the system is explained, and drug safety rules are enforced through penalties, such as loss of access for violators.
Radio-frequency identification (RFID) technology offers an excellent opportunity for restricting solitary access to drugs. RFID uses electromagnetic fields to identify and track tags attached to cards, wristbands or key rings, thus not only restricting access but also logging who opens locks and when. These locks are used at many clinics for everything from controlling entry to parts of a building to tracking who accesses controlled drugs. Newer RFID locks open only if two different tags are used simultaneously. These locks lend themselves easily to the four-eyes system.
Finally, a growing number of clinics are moving to automated drug-management systems like those offered by companies such as Cubex, whose Witness feature requires thumbprint recognition from two approved people before access to controlled drugs is granted.
Drawbacks to Drug Restriction
Practices where veterinarians work alone and need access to medications without the help of others can’t implement a two-person system. Also, let’s not fool ourselves into believing that drug restriction is a complete fix for the suicide problem. For example, restricting drug access does nothing to change access to other, non-pharmacologic means of suicide.
Drug control does not change the underlying causes of suicide. Rather, we should think of drug restriction like a seat belt. That is, seat belts do not address the underlying causes of auto accidents but can save lives during a crash. Likewise, restrictions don’t change the circumstances that lead someone to consider suicide, but they can make a lifesaving difference in a critical moment. To save more lives, drug restrictions must be combined with other efforts designed to address underlying causes.
- Easy to implement
- Highly flexible
- Minimal impact on practice efficiency
- Minimal cost
- Utilizes two-lock systems in place in many practices
- Works in combination with other mental health/suicide initiatives
- Stimulates discussion and awareness within practices
- Difficult to implement when veterinarians work alone
- Limits access to pharmacologic poisons but not other means of suicide
- Does not address underlying causes of suicide
2. Employee Assistance Programs
Another step that clinics can take sooner rather than later is to craft and promote an employee assistance program. An EAP is paid for by the employer and administered by an outside provider that offers free, around-the-clock confidential support and mental health services from professional counselors. In short, it gives employees suffering from personal or work-related problems a place to turn anytime through a simple phone call.
Traditionally, veterinary clinics have struggled with how to support team members who are battling depression, stress or mental illness, especially when these employees do not self-identify as needing help. We are not mental health care providers, after all, and are not always comfortable in that role. We often do not know how to help colleagues who are struggling, or how or where to refer them for assistance. EAPs are a simple, affordable and underutilized tool.
EAPs vary by plan and provider. Services particularly beneficial to veterinary professionals include 24/7 mental health counseling, grief counseling, self-help libraries, and assistance in finding affordable elder care, child care and pet care. Some offer budgeting resources and even financial support. EAPs can be particularly useful in scenarios involving burnout, compassion fatigue, financial stress, divorce, new or first job stress, anxiety, substance abuse and depression.
EAPs generally provide 24-hour phone access to mental health professionals who provide short-term, solution-based counseling, assessment or referrals. While long-term treatment doesn’t fall under the EAP umbrella, a counselor can point someone to such care. Regular, ongoing treatment options might then be covered by health insurance, or if that option is not available, at private or community care providers. Many EAPs offer management consultations to clinic leaders and can provide grief counseling and onsite support after incidents that affected the entire team.
Finding an EAP provider that meets your practice’s needs makes a big difference. The good news is that most plans are affordable. For example, the Veterinary Hospital Managers Association offers a group EAP starting at $50 a month. Program costs vary with the services provided and can range from $10 to $100 annually per employee, according to Small Business Trends. If your practice offers employee health insurance, you might reap added benefits by purchasing your EAP through the insurer.
Keys to Utilizing EAPs
The greatest shortcoming for most EAPs is a lack of awareness. Employees simply don’t know the EAP exists or do not understand the menu of services. EAPs regularly have low utilization rates, which are generally attributed to the stigma of seeking mental health help and the lack of ongoing promotion.
For EAPs to be beneficial, a clinic must promote the service regularly so that it’s top of mind when a staff member is struggling. Posting educational materials in employee restrooms and break rooms is one way to keep visibility high.
Bonus idea: Every time you remind and educate staff about your clinic’s EAP, you’ll prompt conversations around wellness and mental health, reduce the stigma of depression and mental illness, and show employees that their well-being matters to their colleagues and the clinic.
Drawbacks to EAPs
Not all EAP providers are licensed to provide mental health services in a particular state, so you will need to confirm the terms. Also, quality varies widely among EAP providers. Some might assist clinics in raising awareness of the program through printed materials, email reminders and in-clinic presentations, while others might provide no such support.
When comparing EAP plans, look for variations based on price and provider. For example, some plans offer employees up to six counseling sessions for an issue per year, but others might offer only a single session. So, do your homework before your clinic signs up for an EAP. With a little time and research, finding the right plan shouldn’t take long.
- Generally affordable for clinics
- Wide variety of options
- Confidential for employees
- 24/7 access to mental health professionals
- Helpful in both work and personal situations
- Provide short-term solution-based counseling
- Assist in mental health assessment and referrals
- Often provide digital self-help tools
- Might provide onsite support
- Maintaining awareness is an ongoing challenge
- Variation in quality, services and prices requires initial research
- Licensing in your state is not guaranteed
- EAPs do not provide long-term care
Suicide is undeniably a disturbing problem in veterinary medicine. We should all be aware of it and:
- Work continuously to encourage mental health initiatives within our profession.
- Support the emotional, mental and financial well-being of our colleagues and employees.
- Advocate for multifaceted interventions at every level.
While taking those steps, we can make a significant difference in the short term by restricting access to lethal drugs whenever possible and providing mental health support to team members through an employee assistance program. Such simple, affordable actions will serve to reduce the risk of suicide and increase the chances of getting help to veterinary professionals in crisis. That is how we start saving lives.
Visit the NAVC’s Spark! video gallery to hear from Lisa Stewart-Brown, Banfield Pet Hospital’s health and wellness program manager, as she addresses mental health and suicide. The three-part series consists of: