Administration and Leadership, Columns

Study Shows Lack of Peer-Reviewed Research on EMS Provider Suicide

Issue 6 and Volume 41.

A Stunning Deficit

Stanley IH, Hom MA, Joiner TE. A systematic review of suicidal thoughts and behaviors among police officers, firefighters, EMTs, and paramedics. Clin Psychol Rev. 2016;44:25-44.

In previous columns we’ve touched on the care we provide for patients with thoughts of suicide (see the June 2013 and October 2015 issues). This month we focus inward.

Background: Recent reports, such as “Critical Stress: Survey reveals alarming rates of EMS provider stress & thoughts of suicide” in the October 2015 issue, indicate suicide rates among EMS practitioners have been rising and that the amount of providers suffering from post-traumatic stress disorder (PTSD) is higher than we think. Sources of these reports are largely from industry trade publications and professional associations, such as the Code Green Campaign, a nonprofit organization founded by EMS practitioners in 2014. The study in this month’s column is a systematic review of the literature used to determine suicidality, including ideation and attempts, among not just those in EMS, but all first responders.

Methods and results: Through a structured search of six databases, the authors were able to find 63 articles meeting pre-established inclusion criteria: English-language peer-reviewed publications having quantitative data about suicide or suicidal behavior, and focusing on police officers, firefighters, EMS practitioners or a combination thereof. Within these articles, 49 focused on police officers, nine on firefighters, two on EMS practitioners, and four on more than one category of responder.

The authors conclude that a relatively large body of research is available for police officers. They also offer a useful column labeled “limitations” for each study. Many of the studies had insufficient methodological reporting and lack of randomized control trials. None of the identified studies examined the link between PTSD and suicide among firefighters and EMS practitioners.

The EMS-specific literature consisted of one Norwegian study showing lower levels of suicidal behavior among EMS practitioners compared to medical students and young physicians, and a study reporting several suicides-and potential suicides-among EMTs in New York City in 1992. The New York City study didn’t include any comparison groups, making it difficult to ascertain a difference between suicide among EMS practitioners and any other specified population.

Another study, one of the nine specific to firefighters, found suicide attempts were six times higher among firefighters belonging to departments that also provide EMS response. The authors noted the deficit in available literature focused on suicidal behavior among EMS practitioners and identified a need for further research.

Discussion: This study concludes all first responders may be at an elevated risk of suicidal behavior. One reason for this is the presence of PTSD, which has a statistically significant correlation with suicidality. The authors postulate that first responders may be at an increased risk for PTSD as a result of their repeated exposure to traumatic events. Other reasons for an increased risk of suicidality are occupational stress and dissatisfaction, fewer years of service, marital problems and sleep disturbances.

Conclusion: The authors of this study searched rigorously for any literature relevant to EMS practitioners and found a stunning deficit. They suggest the findings of their review, with regards to EMS practitioners, are so limited as to make any larger generalizations impossible.

Bottom Line:

What we already know: There’s been a lot of attention on PTSD and suicide within the EMS community.

What this study adds: There’s a striking lack of peer-reviewed research surrounding EMS practitioner suicide and suicidal behaviors.

Suffering Down Under

Media reports over the last few years in Australia have indicated a concern regarding suicide in emergency service workers.

One report, “Alarm at suicide for paramedics,” published in the newspaper The Age in May 2012—and often cited since publication—claimed that the rate of suicide among Victorian paramedics was 20 times higher than the general population.

These reports led Curtis, Hodgson and Wallis (in work that hasn’t yet been published) to complete a scoping review in early 2015 to determine if Australia’s emergency personnel commit suicide more than the general public. Like Stanley, Hom and Joiner, their review found a lack of data pertaining to suicide in emergency personal.

Further light was shed on the subject in the June 2015 report released by the Coroners Court of Victoria on the incidence of suicide in several occupations from 2008-2014. The prevalence rates listed for each occupation were compared to the Victorian average annual suicide rate of 10.9 per 100,000, as well as the Victorian employed population suicide rate of 8.9 per 100,000.

Both police and fire services personnel’s suicide rate per 100,000 hovered around the norm for the general population; police at 10.0 and fire or emergency workers grouped together at 10.5. Victorian paramedics, however, had a significantly higher annual average suicide rate of 35.6 per 100,000.

Although it’s not the 20 times higher than the general population rate as reported in the media, it’s three times as high, which is concerning to those working in EMS. As this data is only extrapolated from Victorian sources, it causes a limitation when trying
to draw parallels interstate, Australia-wide and internationally.

Additionally, no determination can be made from the literature as to why paramedics have a higher suicide rate compared with other emergency services.

Visit for audio commentary.