Abstract
Objectives
This study assessed cat owners’ perceptions of the use of psychoactive medications and alternative products for the treatment of behavioral problems in their cats. Factors that potentially impact these perceptions were explored and discussed.
Methods
An online, anonymous, cross-sectional survey was conducted to assess US-based cat owners’ experiences with behavior problems of their cats, familiarity with psychoactive medications for treatment of behavior problems and comfort levels using the following products for treatment of feline behavior problems: fast-acting or situational prescription medications, slow-acting or long-term prescription medications, herbal/nutritional supplements, pheromone products and cannabinoid products.
Results
Many respondents reported that their cats had behavioral problems, but few had ever sought behavioral help for their cats. Only half were aware of the availability of psychoactive medications for cat behavior problems. Respondents who had personally used a prescription psychoactive medication in the past were more comfortable with giving fast- and slow-acting prescription medications, pheromone products and cannabinoids to their cats than respondents who had never used a prescription psychoactive medication. No difference in comfort level was seen for herbal/nutritional supplements. Overall, owners tended to be more comfortable with the situational vs long-term medications.
Conclusions and relevance
Given the prevalence of feline behavior problems reported in this study, the lack of awareness of either the availability or potential benefits of psychoactive medications for the treatment of feline behavior problems, and the fact that very few owners had ever sought help for behavior problems with their cats, are concerning. These results suggest a missed opportunity for veterinarians to help clients identify, understand and treat feline behavior problems. Many owners appear open to these treatment options for their cats; it is suggested that, when warranted, educating cat owners about the potential benefits and risks of these medications would be of value.
Keywords
Introduction
The behavior of companion animals plays an essential role in the formation and maintenance of the human–animal bond. 1 Behavior problems (and the damage they can do to this bond) are a leading source of relinquishment and euthanasia for domestic cats.2–4 A recent American Animal Hospital Association report stated that more domestic cats are negatively affected by behavioral problems than by any other condition. 5
Certain psychoactive medications, herbal supplements and pheromone products have been shown to be safe and effective aides for the treatment of several behavioral conditions in cats.6–10 However, veterinarians often encounter resistance from owners when recommending these treatment options. 11 Social stigmas and negative attitudes regarding the use of psychoactive medications have been well established in human medicine,12,13 and may decrease patient adherence to treatment recommendations, thus posing a barrier to appropriate treatment of major depressive disorder in humans. 14
To our knowledge, owners’ attitudes towards the use of psychoactive medications and other, alternative options, such as herbal supplements and pheromone products for their pet cats, have not been explored, even though the perceived stigma associated with these medications and products has been cited as a possible reason for their infrequent use. 2 Given the significant risk of untreated behavior problems to domestic cats and to the bond that these cats have with their human companions, the present study aims to assess cat owners’ perceptions regarding the use of psychoactive medications and alternative products for the treatment of behavioral problems in cats. Factors that potentially impact these perceptions, including owners’ personal histories with prescription medications and non-prescription psychoactive herbal or nutritional supplements for anxiety or depression, are explored and discussed.
Materials and methods
An online, anonymous, cross-sectional survey (see supplementary material) was developed using Qualtrics. The survey was designed, reviewed and tested by the co-investigators and their colleagues (veterinary and applied animal behavior professionals) after seeking input from representatives from the community who currently owned a cat. Representative cat owners were asked to provide feedback on content, navigability, survey questions and choices, and overall questionnaire design. Revisions were made based on this feedback in an ongoing process that involved several reiterations. After this step was completed, the survey was pilot tested by 10 individuals for any additional ambiguity and/or potentially missing or inappropriate response options. In addition, five academic veterinarians (colleagues of the authors) and four veterinarians in private practice assessed face validity of the survey; their feedback was used to further refine the survey questions. The final survey and study design were approved by the Colorado State University Institutional Review Board (IRB #190-18H).
Survey respondents were recruited through Amazon’s Mechanical Turk (MTurk; Amazon) platform, an open online marketplace providing affordable access to over 100,000 potential survey respondents. 15 Diversity of participants recruited through MTurk is high (samples have been found to be more diverse than typical Internet samples or American college-based samples), and the quality of data collected meets or exceeds the psychometric standards considered acceptable in published research in the social sciences. 15 To minimize the influence of geographic and cultural differences on respondent data, the survey was made available to responders based in the USA only. Adult (18 years or older) participants who were the current or past primary owners of at least one cat were recruited for the study, and demographic data were collected (age group, sex and education level, and confirmed current or past cat ownership).
Respondents’ level of knowledge about the existence and causes of behavior problems in cats was assessed. Five-point Likert scale questions were used to assess owners’ comfort levels using the following products in the treatment of feline behavior problems: fast-acting or situational (FA) prescription medications; slow-acting or long-term (SA) prescription medications; herbal, nutritional or ‘natural’ supplements (eg, Rescue Remedy); pheromone products (eg, Feliway); and cannabinoid (CBD) products. A brief description of each product category and an example of clinical indication (eg, aggression, anxiety during transport) was provided. The relative importance of various factors that may impact an owner’s decision-making process was explored, including side effect concerns, cost, ease of administration, social stigma, proven efficacy, word of mouth (friend or relative’s experience giving the product to their cat) or recommendation from a veterinarian. Finally, cat owners were queried about their personal use of psychotherapeutic medications or alternatives, and their experiences (positive, negative or neutral) with each.
In addition to descriptive statistics, associations between comfort levels with various products and respondent characteristics (demographics, personal histories and experiences of taking psychoactive medications, and personal histories of taking non-prescription psychoactive supplements or herbal remedies) were analyzed using non-parametric approaches best suited to categorical and Likert (ordinal) data (Mann–Whitney U-test, Kruskal–Wallis non-parametric ANOVA and χ2). 16 Data were analyzed using XLSTAT (Addinsoft) for Microsoft Excel. All tests were two-tailed; significance level (α) for all analyses was set at P = 0.05.
Results
The complete published survey, showing all question and response wordings, is provided as supplementary material. A total of 448 responses were obtained from the MTurk survey; most (68.9%) respondents were aged 18–40 years, and 64.7% of respondents were female. Most (69.9%) respondents had at least some college experience (34.4% reported completing some college or 2 year college, 35.8% completed a 4 year degree); the remaining participants were almost evenly split between those possessing a high school diploma or GED (General Equivalency Diploma; 14.7%) and those having postgraduate degrees (15.2%).
The majority (89.7%) of respondents reported currently living with at least one cat; the remaining 10.3% had lived with a cat in the past. The vast majority of respondents (93.5%) believed that cats could have behavior problems based on anxiety or other emotional problems.
Very few respondents had ever sought behavioral help for their cats: only 16 (3.6%) reported consulting a behaviorist for help with behavior problems exhibited by their cats. Only 15 (3.3%) had had a veterinarian recommend that they seek behavioral help for their cats. Despite this, the majority (97.8%) of respondents reported that their cats had at least one behavioral problem (Table 1).
Behavior problems reported by cat owners, in order of prevalence
Mathematical average of 2.4 reported problems per owner; note that some cats may have had multiple problems reported and others none
Respondents’ awareness of psychotherapeutic medications for cat behavior problems was divided fairly equally between those who reported being aware (50.2%) and those not aware (49.8%). However, females were significantly more likely than males to report being aware of these options (56.6% of women were aware of these medications vs 37.2% of men [χ2 = 19.3, df = 2, P <0.0001]). Age was also significantly related to awareness (χ2 = 16.3, df = 5, P <0.006); respondents in the age group 18–30 years were less likely to be aware of these options (58.6% unaware), and respondents aged 41–50 years were more likely to be aware (66.2% aware) than other age groups. In other age categories, the split between aware and unaware was more evenly distributed. There was no significant relationship between education level and awareness level.
When asked whether they would consider giving psychoactive medications or supplements to their cat for behavior problems, responses were mixed: 21.4% replied ‘Yes’ and 21.2% replied ‘No’; the remainder (57.4%) replied ‘Maybe’. The most commonly cited concerns related to giving psychoactive medications or supplements to their cat were negative side effects (73.3% of respondents), excessive sedation (63.9%) and the possibility of their cat becoming addicted to the medication (39.9%). Of the various factors that may impact a cat owner’s decision-making process with regard to the use of psychoactive medications in their own cats, owners most frequently rated proven effectiveness (89.7% of respondents), ease of administration (84.8%), veterinarian recommendation (81.5%) and cost (77.0%) as important or very important in their decision (Table 2). Conversely, the majority of respondents (71.6%) reported that the opinions of others were not very important or not important at all in their decision-making process (Table 2).
Relative importance of factors in cat owners’ decision-making process about the use of psychoactive medications for their cats (response mode highlighted in bold; n = 448)
The percentages of respondents who had vs had not ever taken a prescription psychoactive medication themselves were roughly equal: 48.4% of respondents had never taken a prescription medication for anxiety or depression; 51.6% reported they had taken such medication at some time (present and/or past). Of those who had taken a prescription psychoactive medication, 58.0% rated their experience with the medication as positive (27.3% neutral, 14.7% negative).
Respondents’ experience with non-prescription medications or supplements for anxiety or depression was not as evenly distributed: 71.7% of respondents reported never having taken a non-prescription medication or supplement for these concerns (28.3% had taken such medication or supplements in the past). Of those who had taken a non-prescription medication or supplement for anxiety or depression, 58.7% rated their experience as positive, with only 4.8% reporting negative experiences (36.5% neutral).
Patterns in comfort levels with various therapeutic options
Comfort levels with the use of psychotropic medications and products among respondents with and without a history of personal prescription psychoactive medication use are shown in Table 3; comfort levels among respondents with and without a history of personal use of non-prescription products and supplements are shown in Table 4. In analyzing the differences in comfort levels between respondents with a history of personal prescription medication (n = 231) or non-prescription supplement (n = 126) use vs those with no history of using these medications (n = 217) or products (n = 320), and to avoid pseudo-replication within the data from respondents who had used both prescription and non-prescription medications, respondents were divided into four categories for analysis. These were respondents who had used: (1) prescription psychoactive medications only (n = 127); (2) non-prescription supplements only (n = 24); (3) both prescription and non-prescription products (n = 102); and (4) neither prescription nor non-prescription products (n = 193). Following the overall four-way group analysis, pairwise comparisons were conducted to assess differences between individual categories.
Respondents with a history of personal prescription psychoactive medication use (categories 1 and 3) were more comfortable with using FA prescription medications (K = 16.695, P <0.002) and SA prescription medications (K = 25.206, P <0.001) with their cats than respondents with no history of personal prescription psychoactive use. These differences were supported in the pairwise comparisons, with strongest differences found between respondents with (categories 1 and 3) vs without (categories 2 and 4) a history of prescription psychoactive medication use. Respondents with a history of non-prescription products only (category 2) were less comfortable with the use of SA prescription medications than respondents with a history of prescription medication use only (category 1) (W = 3.854, P <0.04). This difference was not significant for the other treatment options (FA, herbal/nutritional supplements, pheromones or CBDs).
There was a significant difference between groups in comfort levels using pheromone products for their cats (K = 11.022, P <0.02), largely driven by the significantly higher comfort levels in respondents with personal history with both prescription and non-prescription products (category 3) vs respondents with no history with either product (category 4) (W = 4.483, P <0.009). Similarly, respondents with a history of prescription psychoactive use were more comfortable with use of CBD products than respondents with no such history (K = 11.868, P <0.009), with overall differences driven largely by the significant difference between categories 3 and 4 (W = 4.445, P <0.01). No significant differences in comfort levels between groups were found for herbal/nutritional supplements. Interestingly, respondents with a history of prescription medication use only (category 1) tended to be slightly less comfortable with use of the non-prescription alternatives in their cats than respondents with a history of non-prescription products only (category 2), although the differences were not statistically significant.
Frequency of comfort levels with treatment options in cat owners with a history of personal prescription psychoactive medication use (n = 231), and cat owners with no history of personal prescription psychoactive medication use (n = 217)
FA = fast-acting or situational prescription medication; SA = slow-acting or long-term prescription medication
Frequency of comfort levels with treatment options in respondents with a history of non-prescription herbal or nutritional supplement use (n = 126), and respondents with no history of use of these products (n = 320)
FA = fast-acting or situational prescription medication; SA = slow-acting or long-term prescription medication
For cat owners with a history of personal prescription psychoactive use, we investigated whether the nature of the respondents’ reported experience with these medications (positive, negative or neutral) (n = 229) was associated with their comfort levels with the five treatment options. The cat owners who had had a positive or neutral experience with prescription psychoactive medications were more comfortable with using SA medications with their cats than those cat owners who reported a negative experience with prescription psychoactives (K = 22.529, P <0.0001). No significant differences were seen between respondents reporting positive, neutral or negative experiences in comfort levels with the use of the other four treatment options.
We also investigated whether demographic variables such as education level, age group or sex affected comfort levels with the five treatment options. Respondents possessing a high school diploma/GED or a 4 year college degree tended to be less comfortable with the use of FA psychoactive medications (W = 8.582, P = 0.035) and pheromones (W = 10.518, P = 0.015) than respondents in the other educational categories. No other differences were seen in comfort levels by education level.
The only difference seen in treatment comfort level by age group was for pheromone use; respondents in age groups 41–50 and 51–60 years were found to be more comfortable with pheromone use (W = 15.593, P = 0.008). No other differences were seen in comfort levels by age group.
Female cat owners were more comfortable than male owners with the use of FA medications (U = 25861, P = 0.006), herbal/nutritional supplements (U = 25414, P = 0.016) and pheromones (U = 27944, P <0.0001) for their cats. No differences in comfort level by sex were seen for SA medications or CBD.
Discussion
Given the prevalence of feline behavior problems, it is concerning that half of the cat owners surveyed in our study were unaware of the availability or potential benefits of psychotherapeutic medications for the treatment of behavior problems in their cats. In addition, very few owners had ever sought help for behavior problems with their cats, and only 3.3% of owners reported that their veterinarian had recommended that they seek behavioral help for their concerns with their cats. These results are striking, in light of the number of feline behavioral problems reported by these cat owners (Table 1). Cat owners in our study reported a combined total of 1092 behavioral problems with their cats.
The majority of owners surveyed reported that they would or might consider giving psychoactive medications or supplements to their cats. Many owners appear open to this treatment option for their cats; it is suggested, therefore, that educating cat owners about the potential benefits and risks of these medications would be of value.
Social stigma did not appear to be a major factor in owners’ attitudes about use of these treatment options in their cats, as the majority of respondents ranked ‘opinions of others’ as unimportant in their decision-making process. Unlike in human medicine, therefore, stigma appears unlikely to pose a significant barrier to the treatment of feline behavior problems. The most commonly cited concerns about these medications involved the possibility of negative side effects, sedation and addiction, and concerns appeared greater for daily (SA) medication use. Thus, it is important for veterinarians prescribing these medications to discuss these concerns, and educate owners about the likelihood of side effects and how to address them should they occur. Discussions about potential side effects of psychoactive medications should be tailored to the individual medication used, as side effect profiles differ between medications. 17 For example, fluoxetine is commonly prescribed to treat feline urine marking; 8 side effects of fluoxetine are usually self-limiting and may include reduced appetite, and rarely vomiting and lethargy.8,18
These results suggest a missed opportunity for veterinarians to help feline-owning clients prevent, identify, understand and treat behavior problems in their cats. This gap in services may be partially explained by the minimal training many veterinary students receive in preventing, diagnosing and treating behavior problems, resulting in a lack of confidence in practicing behavior medicine and, in turn, a lack of behavioral services being offered by many veterinary practices.19–22 Studies have shown that many owners of companion animals rely on sources other than veterinarians for behavioral advice for their pets, 5 and the quality of the advice they receive is likely highly variable, as has been shown for dogs. 23
The risks of untreated behavior problems in companion animals (relinquishment or euthanasia of the pet, damage to the human–animal bond, safety risk to the human household) have been noted elsewhere.3,24,25 Proactively providing owners with advice regarding their own behavior towards their cat, the species-specific needs of cats, and appropriate training and socialization for kittens, can reduce the number of undesirable behaviors reported by owners.5,26 Client (and patient) retention is another reason for veterinarians to consider feline behavior problems as part of routine visits, even if that consideration is simply a basic discussion of prevention, existing concerns and (if necessary) referral to a qualified behavior expert.
Owners with a personal history of taking prescription psychoactive medications reported feeling more comfortable giving these medications (both FA and SA) to their cats than owners without these personal experiences. This difference extended to a willingness to use pheromone products and CBDs, but it did not extend to the use of herbal supplements. Reasons for this are unclear, although it may be related to levels of perceived efficacy or risks of use for the herbal products. The small number of respondents who had used only alternative approaches (n = 24) may have prevented strong differences from being detected between these respondents and respondents who did not use these products, other than in the case of lower comfort levels with use of SA medications in their cats compared with the comfort levels of respondents using only prescription psychoactive medications.
The general trend was for respondents who reported a history of use of prescription psychoactive medications (regardless of their use or non-use of the non-prescription alternatives) to be more comfortable than respondents with no history of use of prescription psychoactives with use of all of these treatment approaches in their pets (with the exception of herbal supplements, where no differences were seen). Overall, owners tended to be more comfortable using the FA prescription medications than the SA ones (Tables 3 and 4). Perhaps they view the perceived risks associated with the use of SA medications (taken every day, with longer-lasting psychoactive effects) as greater. Alternatively, this difference may be driven by the reported concerns about ease of administration or cost (daily vs periodic).
Owners stated ‘proven effectiveness’ as the strongest factor in their decision-making process regarding use of these products, and ‘negative side effects’ were the most frequently reported concern with use of these products in their own cats. These results underscore the importance of research testing the efficacy and safety of these treatment options. Many psychoactive medications used in veterinary practice to treat behavioral issues are used off-label; very few of these medications have been federally approved in the USA for use in companion animals (Anipryl and Sileo [both manufactured by Zoetis], Clomicalm [Elanco], Reconcile [PRN Pharmacal]; all labeled for use in dogs). Knowledge that these medications are being used off-label may reduce owner confidence in their potential efficacy and/or increase their perception of risks associated with such medications. Evidence to support efficacy and safety of alternative treatments is minimal; even pheromone products, the most studied to date of these alternative approaches, remain controversial among researchers and practitioners. 5
Client education can be improved by following recommendations made in the fields of animal sheltering and adult learning. Troughton, 27 when discussing approaches to maximize success when working with potential adopters at an animal shelter, recommended following the principles of adult learning, based on the work of Vella 28 and Zull. 29 These recommendations could also be applied to successful discussion of the use of psychoactive medications to help treat behavior problems in the veterinary clinic.
(1) Respect client’s existing knowledge, skills, beliefs and attitudes. This study provides an overview of cat owners’ current levels of awareness of these medications and willingness to use them.
(2) Allow clients autonomy to make decisions about what is best for them, given their unique circumstances. Table 2 in this paper will help practitioners consider the factors influencing cat owners’ decisions about the use of these medications.
(3) Make clear the relevance and immediacy of the information you are providing; how can these treatment approaches make life better for both the human and feline household members? This is particularly important given the lack of awareness of these treatment approaches among many cat owners. Awareness of these options and the potential benefits of treatment (and risks of lack of treatment), not just to their cats, but to the owners themselves, can be a strong intrinsic motivator to enhance learning and client adherence.
(4) Ensure that clients feel safe and comfortable during the behavior-related conversations and resultant recommendations. A client who feels uncomfortable or threatened is unlikely to absorb new information and/or follow treatment recommendations; correct misconceptions about medications in a non-judgmental, non-confrontational manner.
With any survey-based study, potential for selection bias exists. For example, roughly half of our respondents reported having experience (current and/or past) with prescription psychoactive medications. This is higher than the use of these medications (eg, antidepressants, anxiolytics) by adults in the US population as a whole, as reported elsewhere; for example, one recent study reported that one in six adults (16.7%) had used psychoactive medications in 2013. 30
Use rates were higher in women than men, and a larger proportion of respondents in our study were female, which may partially explain the discrepancy. In addition, our survey asked about current and/or past use, whereas many published surveys focus on current rates of use (and we would expect the proportion to have ever used such a medication to be higher than the proportion who currently use them). Finally, rates of use of these types of medication are increasing, as reported by Moore and Mattison, 30 and others, and our survey data represents 2018 use.
Nonetheless, the relatively high proportion of respondents reporting history of use of prescription psychotropics in our study could reflect a selection bias, if such respondents were more likely to participate in the survey based on the survey’s focus (as reflected in the title of the survey: ‘Cat Owner/Guardian’s Perceptions of Psychotherapeutic Medications, Supplements, and Pheromones’). If this selection bias was present, awareness of the existence of psychotherapeutic medications for treatment of feline behavior problems may be even lower than our study suggests. However, Amazon’s MTurk online platform was used in this study to reduce bias by selecting anonymous respondents, and MTurk has been shown to recruit relatively diverse participants. 15 In addition, compensation for participation has not been shown to affect quality of data from this platform, with quality of data being at least as reliable as those obtained via other, more traditional survey methods. 15 Finally, we did have a significant proportion of respondents (48.4%), with no history of personal psychotropic medication use.
Conclusions
This study found that past history with prescription psychoactive medications plays a role in cat owners’ comfort using these types of medications with their own cats; perhaps not surprisingly, owners with personal experience with these medications were more likely to consider using both fast- and slow-acting psychoactive medications for their pets. The majority of owners surveyed reported that they would use, or might consider using, psychoactive medications or supplements with their cats, but awareness of these approaches is lacking. This is despite the high numbers of behavior problems reported.
These results align with earlier studies noting the lack of behavioral medicine practiced in many veterinary clinics, caused at least partially by the deficiency of veterinary behavior as a core requirement in most veterinary curriculums. All veterinary students should receive sufficient training: to be comfortable initiating conversations about behavior with their clients; to proactively work towards prevention of behavior problems by educating clients about cat behavior, needs and body language; and to either treat reported issues themselves or refer these cases to a qualified applied animal behavior professional. Further research into these treatment approaches is clearly needed to reduce owner concerns and off-label usage and, at the same time, increase awareness and appropriate, warranted prescriptions.
Supplemental Material
Supplementary Material
The online survey
Footnotes
Supplementary material
The following file is available online:
The online survey.
Conflict of interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
Funding for this study was provided by E Grigg (UC Davis FYS academic enrichment funds, feline and canine cognition). This study was conducted with approval from the Colorado State University Institutional Review Board (IRB #190-18H).
References
Supplementary Material
Please find the following supplemental material available below.
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