Administration and Leadership, Exclusives

First Responders and PTSD: A Literature Review

Ashley Fitzpatrick writes the time has come to put the mental health needs of our first responders before their call of duty. (Photo/National Highway Traffic Safety Administration)

Abstract

The mental health of first responders is often overlooked. Increases in mental health issues, post-traumatic stress disorder (PTSD) and rates of suicide have prompted research into what first responders need in order to stay emotionally healthy. The time has come to put the mental health needs of our first responders before their call of duty. Exposure to traumatic events has been linked to psychological distress and many frontline workers experience these traumas on a daily basis. Literature suggests that the increased incidences of psychological distress requires extensive scientific inquiry into the mental health of first responders worldwide.

Related

First Responders Suffering

There is a silent crisis happening worldwide. First responders are quietly suffering because of the stigma surrounding the utilization of mental health services. First responders are more likely to suffer from psychological distress due to job stress, repeated exposure to trauma, lack of sleep, the physical demands of the job, lack of resources and working long hours or multiple jobs.

The community of first responders have been neglected and now they are beginning to show the consequences of such neglect. The immediacy of care is of the utmost importance for all individuals suffering with a mental illness or condition.

The community of first responders must begin accepting mental illness as they would any other physiological condition.1 The first responder community must end the stigmatization of mental health and bring awareness, as well as normalcy, to end this silent killer. The trauma that first responders experience throughout their careers are not normal instances however seeking help is what should be considered normal. 

A review of existing literature published within the last 10 years was completed utilizing the electronic databases PubMed and Google Scholar. Forty-eight articles were further evaluated for this literature review, 15 were utilized. Articles were chosen based on the following inclusion criteria: (1) the article examines one or more first responder occupations defined as police officers, firefighters, emergency medical services, emergency medical technicians, paramedics and/or dispatchers; (2) presents data on one or more of the following topics: post traumatic stress disorder (PTSD), suicide, substance abuse, dual diagnosis, depression and/or anxiety, non pharmacological interventions, pharmacological interventions, therapy; (3) published in English.

Articles were excluded if they contained the following: (1) large scale incident studies; (2) military-specific articles; (3) first responders responding to mental health crisis patients.

The three themes signify how the data from the articles was separated. Theme one reports findings in relation to police, fire, and EMS. Theme two discusses PTSD and suicide. Lastly, theme three examines different treatment modalities and their outcomes.

Emergency Medical Services, Fire and Police

All literature points to the same conclusions. The data suggests that first responders are at an increased risk of PTSD and issues with mental health however rigourous studies need to be conducted in order to be able to generalize the data and apply it to all first responders. In a survey study completed in Canada, researchers found that out of 5,813 participants (32.5% women) were grouped into six categories (i.e., call center operators/dispatchers, correctional workers, firefighters, municipal/provincial police, paramedics, Royal Canadian Mounted Police). Substantial proportions of participants reported current symptoms consistent with one (i.e., 15.1%) or more (i.e., 26.7%) mental disorders based on the screening measures.2

The researchers reported that the participants’ symptom clusters were consistent with one or more mental disorders, concluding that the incidences of mental illness were higher than previously published estimates compared to the general population.

Harvey et. al examined the impact of repeated trauma exposure in firefighters from Australia. A cross-sectional survey was completed by current (n=488) and retired (n=265) firefighters from Fire and Rescue New South Wales, Australia.

Among current fire-fighters, rates of post-traumatic stress disorder and depression were 8% and 5%, respectively; while 4% reported consumption of more than 42 alcoholic drinks per week. Retired firefighters reported significantly greater levels of symptomatology, with the prevalence estimates of post-traumatic stress disorder at 18% (p = 0.001), depression at 18% (p < 0.001) and heavy drinking at 7%. There was a significant positive linear relationship between the number of fatal incidents attended and rates of post-traumatic stress disorder, depression and heavy drinking.3

Conclusions can be drawn from this study that there is a link between trauma exposure, PTSD, depression and substance abuse. Not only do the studies find a correlation between trauma exposure and psychological distress in paid firefighters, it has also been observed in volunteer fire services. Milligan-Saville et al. notes that volunteer fire services in Western countries (Australia) have a significant lack of access to support services for mental health issues.

In a cross-sectional survey of an Australian volunteer fire service (n=459), it was found that: The risk of probable PTSD was significantly higher for those with the most frequent involvement with distressing incidents and the highest levels of cumulative trauma exposure. Being trapped in a dangerous situation or being assaulted by other people, resulted in the greatest odds of developing a mental disorder. Volunteer fire service members with the highest levels of trauma exposure and involvement with particular types of critical incidents are at elevated risk of mental health problems. 4

Results yielded that the “estimated prevalence of probable PTSD and psychological distress in the sample were 5.4% and 9.8% respectively, with 11.8% suffering from probable mental disorder.” There is a correlation in their study between the number of traumatic events and greater odds of PTSD (p=0.01), psychological distress (p=0.02), and probable mental disorder (p=0.01). The more traumatic events a firefighter responded to, the higher incidence of PTSD, psychological distress, or probable mental disorder.

Lee et al. evaluated police officers in South Korea utilizing a cross-sectional study.5 Their goal was to evaluate police officers job characteristics and their risk for PTSD. Using the Impact of Event Scale (revised Korean version) they defined police officers to be high risk with a score of greater than or equal to 26. Police officers (n=3187) that had experienced a traumatic event within a one year period were included in the study. Results showed that “41.11% were classified as having a high risk of PTSD.”

Comparatively, Nelson and Smith studied police officers (n=134) and their mental health in Jamaica. The study aimed to examine the relationship between work and mental health. The goal was to assess if there was a correlation between work (job satisfaction and job stress) and mental health outcomes using a cross-sectional survey design. Results reported that: negative work characteristics, lower levels of positive work factors and work support and emotion-focused coping styles were associated with increased levels of depression (F(8, 125) = 7.465, P < 0.001). Subjective feelings of anxiety were positively associated with negative work characteristics and emotion-focused coping (F(8, 125) = 7.586, P < 0.001). The relationship between work characteristics and mental health outcomes was mediated by perceived stress.6 Nelson and Smith recommended that intervention programs should address working conditions and should monitor stress levels.

There is a noteworthy relationship between emergency medical services, firefighters and police officers when comparing all of the articles. Studies show that first responders are at an increased risk of post-traumatic stress disorder and additional mental health issues including substance abuse. The data does not conflict between articles. Concluding statements for most of the articles note that there is a lack of large, national or international studies to verify results between these groups. Though the compilation of data is compelling, the need for additional research is imperative.2,3,5,6

Post-traumatic Stress Disorder and Suicide

PTSD is immensely underreported as utilizing mental health services is seen as weakness in the prehospital and first responder communities. A study conducted using in-hospital and prehospital providers found that “prehospital providers were significantly more likely to screen positive for PTSD compared to the in-hospital providers (42% vs. 21%, P<0.001).”7

Interestingly, this survey found that only 55% of respondents had ever received any information or education about PTSD, and only 13% of respondents sought treatment for their symptoms. Astoundingly, though emergency service personnel experience prominently higher rates of post traumatic stress, there are no rigorously conducted trials for PTSD in this population.8

According to the National Fallen Firefighters Foundation, firefighters are three times more likely to die by suicide than a line of duty death. “In 2016, The Badge of Life, a police suicide prevention program, revealed that nearly 108 law enforcement officers took their own lives. According to the Firefighter Behavioral Health Alliance, an estimated 113 firefighters and paramedics took their own lives in 2015.”1

From a study published in the Journal of Emergency Medical Services researchers found that first responders (EMS) in the United States were approximately 10 times more likely to have suicidal ideations and/or attempt suicide compared to the CDC national average. “The results showed that 3,447 (86%) of the 4,022 respondents experienced CS, but the shocking discovery was that 1,383 (37%) of the respondents had contemplated suicide and 225 (6.6%) had actually tried to take their own life.” (Barber et al., 2015). In the survey, CS (critical stress) was defined as “the stress we undergo either as a result of a single critical incident that had a significant impact upon you, or the accumulation of stress over a period of time. This stress has a strong emotional impact on providers, regardless of their years of service.”9

In some states, emergency medical services (EMS) are not considered an essential service. In these places, EMS does not receive taxpayer money for their services, thus their access to resources and funding is significantly lower than their emergency counterparts. This issue leads to increased stress in the workplace, in addition to “their experiences of life-threatening situations and acute stress” which could further lead to the development of posttraumatic stress disorder (PTSD) or posttraumatic stress symptoms.10

Firefighters were also found to have an increased risk of suicidal thoughts and behaviors. In a study conducted by Stanley et al. (2015), data was obtained via online cross-sectional survey that was distributed nationwide (n=1027) to both active and retired firefighters. Suicidal ideations and behaviors were assessed using a modified version of the Self-Injurious Thoughts and Behaviors Interview-Short Form (SITBI- SF). This study reports the career prevalence estimates of 46.8% (suicidal ideations), 19.2% (has a suicidal plan), 15.5% (suicidal attempts), and 16.4% (non-suicidal self-injury).

The researchers noted that the “key factors associated with increased risk for reporting suicidal thoughts and behaviors included lower firefighter rank, fewer years of firefighter service, membership in an all-volunteer department, a history of professionally responding to a suicide attempt or death, and active duty military status.”11 These numbers are frighteningly high and require immediate intervention in the prevention and treatment of firefighter suicidality.

Treatment Modalities

In the world of behavioral health, there are a variety of treatment modalities utilized for different diagnoses. Cognitive behavioral therapy (CBT) has presented positive outcomes in treating first responders with PTSD. CBT sets a goal-oriented, teleological, problem-focused, well-structured—in the here and now—approach, which also focuses on therapeutic alliance and rapport between the CBT therapist and the client.12,10

A study completed by Bryant et al. (2017) examined the efficacy of exposure based cognitive behavior therapy for PTSD in emergency service personnel in a randomized clinical trial. The trial examined the efficacy of brief exposure to traumatic memories (CBT-B) versus prolonged exposure to traumatic memories (CBT-L). Participants were randomized into three groups: CBT-B, CBT-L, and WL (waitlist). The cognitive behavioral therapy groups included 12 weeks of individualized therapy and education, CBT skills building, imaginal exposure (40 minutes for CBT-L, 10 minutes for CBT-B), in vivo exposure, and cognitive restructuring and relapse prevention.

Participants were assessed at their baseline, post-treatment, and had a six-month follow up. Results showed that participants in the CBT groups had greater reductions in PTSD severity (Clinician Administered PTSD Scale), depression, maladaptive appraisals about oneself and the world, and had increased improvements on psychological and social quality of life than the waitlist group whom did not receive any interventions. Researchers did not find a difference in outcomes between the CBT-B and CBT-L groups, and note “that CBT, which can include either long or brief imaginal exposure, is efficacious in reducing PTSD in emergency service personnel.”8

In contrast to cognitive behavioral therapy, Sessa (2017) reports that resistance to treatment for PTSD is high and has found that trauma-focused psychotherapy can be difficult for those who have issues with recalling traumatic memories. Sessa (2017) suggests that using MDMA in conjunction with psychotherapy “appears to facilitate recall of traumatic memories without the user feeling overwhelmed by the negative affect that usually accompanies such memories.”13 Another study completed in 2018 by Mithoefer et al. examined 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for post- traumatic stress disorder in military veterans, firefighters, and police officers. The study aimed to examine the efficacy and safety of 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for treating chronic PTSD in first responders. This study was a randomized, double-blind, dose-response, phase two clinical trial that was completed in an outpatient clinic in the United States. Criteria included service personnel ages 18 years or older, with chronic PTSD (duration of at least six months) and had a Clinician-Administered PTSD Scale (CAPS-IV) total score of 50 or greater. Participants were administered MDMA (either 30mg, 75mg, or 125mg) orally in two 8-h sessions with concomitant psychotherapy. “Participants in the 30 mg and 75 mg groups subsequently underwent three 100-125 mg MDMA-assisted psychotherapy sessions in an open-label crossover, and all participants were assessed 12 months after the last MDMA session. Safety was monitored through adverse events, spontaneously reported expected reactions, vital signs, and suicidal ideation and behavior. This study is registered with ClinicalTrials.gov, number NCT01211405.” 14

The study concluded that those whom had received the full dose of MDMA (75mg and 125mg) had a significant decrease in PTSD symptoms compared to the 30mg group. Symptom severity was decreased in the 30mg group after receiving the additional three psychotherapy sessions with the full dose of MDMA (100-125mg). “PTSD symptoms were significantly reduced at the 12-month follow-up compared with baseline after all groups had full-dose MDMA (mean CAPS-IV total score of 38.8 [SD 28.1] vs 87.1 [16.1]; p<0.0001).” 14 Trials and studies do show positive outcomes when therapy is involved however for those who have chronic PTSD, have suppressed traumatic memories, or have issues recalling traumatic incidences, the use of MDMA is showing to have encouraging outcomes in clinical trials. 

Additional non-pharmacological interventions recommended to treat post-traumatic stress disorder are recreational therapy, animal-assisted therapy, yoga, and acupuncture as well as alternative delivery methods for psychotherapy.15 However, these complementary alternative methods are dependent upon patient preferences and therapy availability. Additional research is also required to examine the efficacy of complementary practices and PTSD. 

In a literature review by Lewis-Schroeder et al. (2018), as previously discussed, evidence indicates that the prevalence of posttraumatic stress disorder (PTSD) is higher among first responders than the general population. However, they present an interesting topic that requires additional research when discussing the treatment of women and PTSD. There are “notable gaps in the literature including the need to investigate why and how women present with different PTSD symptoms than men, and how these differences need to be taken into account in determining appropriate treatment for women.”16

Treatment can begin through identification of a mental health issue by a primary care provider. Robertson (2019) identified that first responders during their annual fitness for duty exams were screened for physical fitness, not emotional wellness for their occupation.17 Utilizing the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (PCL-5) screening tool, first responders (n=152 post intervention) were screened during their primary care visit. Out of the seven responders that screened positive, five (71%) responders received a referral for mental health services. Early identification of psychological distress and PTSD symptoms with education and referral is beneficial to the mental health of first responders.

Summary

The author’s primary intention of this literature review is to clearly identify and bluntly express that an issue exists within the world of emergency services and it is not being adequately addressed. Early identification, intervention, and referrals to mental health providers may be a key in helping to treat PTSD and decrease the incidence of suicide in first responders. The author’s secondary intention of this literature review was to study the efficacy of mental health services in first responders with PTSD, in comparison with those whom do not utilize mental health support services.

The literature reports positive outcomes with both cognitive behavioral therapy and medication supported psychotherapy, dependent upon the severity and chronicity of PTSD symptoms. Utilizing healthy coping mechanisms and exploring the use of complementary and alternative medicinal practices such as meditation or yoga, can have a positive impact on mental wellbeing. First responders must acknowledge that this is a life-threatening issue and it is one that requires immediate intervention.

The problem is extensive as it involves emergency medical services, firefighters, and police officers globally. “As we begin treating mental illness as a normal condition and mental healthcare as a normal avenue for treatment; we will begin the process of promoting a healthier life among those that serve as first responders.”1 Do not think for a moment that a problem does not exist simply because it cannot be outwardly visualized.

References

1. Brown, A. D. (2017). First responders and mental health. Psychology Today, Retrieved from https://www.psychologytoday.com/us/blog/towards-recovery/201705/first-responders-and-mental-health.

2. Carleton, R. N., Afifi, T. O., Turner, S., Taillieu, T., Duranceau, S., LeBouthillier, D. M., . . . Asmundson, G. J. G. (2018). Mental disorder symptoms among public safety personnel in canada.Canadian Journal of Psychiatry.Revue Canadienne De Psychiatrie, 63(1), 54-64. doi:10.1177/0706743717723825 [doi].

3. Harvey, S. B., Milligan-Saville, J. S., Paterson, H. M., Harkness, E. L., Marsh, A. M., Dobson, M., . . . Bryant, R. A. (2016). The mental health of fire-fighters: An examination of the impact of repeated trauma exposure.The Australian and New Zealand Journal of Psychiatry, 50(7), 649-658. doi:10.1177/0004867415615217 [doi].

4. Milligan-Saville, J., Choi, I., Deady, M., Scott, P., Tan, L., Calvo, R. A., . . . Harvey, S. B. (2018). The impact of trauma exposure on the development of PTSD and psychological distress in a volunteer fire service.Psychiatry Research, 270, 1110-1115. doi:S0165-1781(17)32292-8 [pii].

5. Lee, J. H., Kim, I., Won, J. U., & Roh, J. (2016). Post-traumatic stress disorder and occupational characteristics of police officers in republic of korea: A cross-sectional study.BMJ Open, 6(3), e009937-009937. doi:10.1136/bmjopen-2015-009937 [doi].

6. Nelson, K. V., & Smith, A. P. (2016). Occupational stress, coping and mental health in jamaican police officers.Occupational Medicine (Oxford, England), 66(6), 488-491. doi:10.1093/occmed/kqw055 [doi].

7. Luftman, K., Aydelotte, J., Rix, K., Ali, S., Houck, K., Coopwood, T. B., . . . Davis, M. (2017). PTSD in those who care for the injured.Injury, 48(2), 293-296. doi:S0020-1383(16)30722-7 [pii].

8. Bryant, R. A., Kenny, L., Rawson, N., Cahill, C., Joscelyne, A., Garber, B., . . . Nickerson, A. (2019). Efficacy of exposure-based cognitive behaviour therapy for post-traumatic stress disorder in emergency service personnel: A randomised clinical trial.Psychological Medicine, 49(9), 1565-1573. doi:10.1017/S0033291718002234 [doi].

9. Barber, E., Newland, C., Young, A., & Rose, M. (2015). Survey reveals alarming rates of EMS provider stress and thoughts of suicide.40(10) Retrieved from https://www.jems.com/2015/09/28/survey-reveals-alarming-rates-of-ems-provider-stress-and-thoughts-of-suicide/.

10. Papazoglou, K. (2017). Examining the psychophysiological efficacy of CBT treatment for first responders diagnosed with PTSD: An understudied topic.Sage Open, 7(3), 2158244017729407. 

11. Stanley, I. H., Hom, M. A., Hagan, C. R., & Joiner, T. E. (2015). Career prevalence and correlates of suicidal thoughts and behaviors among firefighters.Journal of Affective Disorders, 187, 163-171. doi:10.1016/j.jad.2015.08.007 [doi].

12. Rector, N. A. (2010). Cognitive-behavioural therapy: An information guide. Toronto, Ontario, Canada: Centre for Addiction and Mental Health. 

13. Sessa, B. (2017). MDMA and PTSD treatment: “PTSD: From novel pathophysiology to innovative therapeutics”.Neuroscience Letters, 649, 176-180. doi:S0304-3940(16)30490-6 [pii].

14. Mithoefer, M. C., Mithoefer, A. T., Feduccia, A. A., Jerome, L., Wagner, M., Wymer, J., . . . Doblin, R. (2018). 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy for post- traumatic stress disorder in military veterans, firefighters, and police officers: A randomised, double-blind, dose-response, phase 2 clinical trial.The Lancet.Psychiatry, 5(6), 486-497. doi:S2215-0366(18)30135-4 [pii].

15. Wynn, G. H. (2015). Complementary and alternative medicine approaches in the treatment of PTSD.Current Psychiatry Reports, 17(8), 600-2. doi:10.1007/s11920-015-0600-2 [doi].

16. Lewis-Schroeder, N. F., Kieran, K., Murphy, B. L., Wolff, J. D., Robinson, M. A., & Kaufman, M. L. (2018). Conceptualization, assessment, and treatment of traumatic stress in first responders: A review of critical issues.Harvard Review of Psychiatry, 26(4), 216-227. doi:10.1097/HRP.0000000000000176 [doi].

17. Robertson, E. W. (2019). Implementation of a standardized screening protocol to improve post- traumatic stress disorder surveillance in first responders.Journal of Occupational and Environmental Medicine, 61(12), 1041-1044. doi:10.1097/JOM.0000000000001732 [doi].