Substance use and mental health disorders (MHD) continue to plague the United States irrespective of demographic and socioeconomic boundaries, with estimates of nearly one in five people living with one of the two disorders.1 While some risk factors are often beyond our control, such as genetics, trauma, and a range of environmental factors; pervasive stigma breeds reluctance among any suffering individuals to seek treatment or support. This reluctance is compounded by limited access to treatment and appropriate care, insurance limitations, “codes of silence” and perceived threats to one’s personal and professional life.
- Mental Health and the EMS Provider
- Toward a Better Understanding of Post-Traumatic Stress Disorder (PTSD)
- Psychological Trauma: The Silent Stalker
EMS often arrive first on the scene and provide life-saving care under dangerous, high-pressure and exhausting conditions. Upon successful rescue, many first responders are the first to reach out to disaster survivors to provide both physical and emotional support.2 Despite their dedication to serve, the range and severity of occupational stressors faced by first responders put them at a higher risk of developing mental health and substance use disorders than the rest of the population. However, there are resources and strategies that are available.
Occupational Risk Factors
Being in an occupation that relies significantly on camaraderie, individual EMTs often feel pressured or obliged to take part in team decompression sessions that often take place at bars and typically involve drinking and outward displays of resilience. While these may appear to be fairly normal for some, it may well be the case that one of your peers is living with the difficulties of problematic alcohol or drug use. Individuals are often left feeling unable to reach out for help or even to recognize their own problems, let alone distinguish their experience from the perceived norm associated with their chosen occupation.
About 30 percent of first responders develop mental health disorders, including depression, Acute Stress Disorder (ASD) and post-traumatic stress disorder (PTSD), as compared with 20 percent in the general population.3 Another common occupational risk factor includes acute and chronic exposure to both primary and secondary trauma, the latter referring to the phenomenon of emotional and moral attachment to the experience of the individuals they rescue.
These overwhelming demands from first responders can lead to compassion fatigue, a depleted capacity for empathy that results in various behavioral issues including depression and anxiety. Burnout is a similar phenomenon of exhaustion resulting from occupational strain such as overwork and lack of support from leadership. These conditions have been found to directly contribute to the more than doubled suicide rates among medics than other professionals.4
In addition to the risks of repeated trauma exposure, EMS providers are expected to be on duty for up to 24 hours at a time and can experience trauma and/or violence while on shift. In fact, 69 percent of EMS providers report never having had enough time to recover between traumatic events.5 The length of shifts, poor sleeping conditions while on-call, and prolonged night shifts all disrupt sleep patterns, which could contribute to the possible development of burnout and eventually even depression or substance use disorder.
In addition to PTSD, depression and other mental health conditions, EMS personnel also experience higher rates of problematic alcohol and drug use than the general population.6 In a 2017 published study, Haddock et al. report that women first responders had rates of smoking, alcohol and other drugs that were three times that of the general population.7 In addition to experiencing more job-related trauma than the population at-large, many paramedics also have access to substances that carry the potential for abuse. Among these are the opioid morphine, and benzodiazepine Ativan; both of which are extremely addictive.
Mental health disorders frequently co-occur with other disorders, including substance use, in the EMS workforce, and treatment for these concerns is vital to improve quality of life.8 Yet, EMS workers are often reluctant to seek care to avoid disciplinary action, stigma and other “codes of silence” that prevent peers from reporting any behavior that may alert leadership to the presence of mental health or substance use issues.9
Despite the care EMS workers provide to individuals in life-threatening situations, what happens when the person with a SUD or MHD is the rescuer themselves, who will help them? Will they choose to get help? EMS personnel are often referred to as “heroes” for their life-saving work, but what about when the heroes need rescuing?
Recognizing Signs and Symptoms
Recognizing when mental health, behavioral and substance use issues are becoming problematic is imperative if we are to prevent tragic consequences that often follow this culmination of occupational risk factors. Key indicators involve observable differences one’s own or a peer’s emotional, physical and professional habits over time.
For instance, upon experiencing a single trauma, an individual may experience symptoms of PTSD within three general categories: arousal, avoidance and re-living. Arousal refers to anxiety characterized by persistent feelings of fear of imminent threat which may present as profuse sweating, tremors, physiological symptoms gastrointestinal disturbances and heart palpitations.10
In order to avoid the discomfort of such arousal, individuals may habitually make excuses to shirk responsibilities or renege on social commitments in (conscious or unconscious) attempts to steer clear of people, places or things that stir up memories or feelings closely associated with the traumatic event. This avoidance serves to prevent the individual from re-living their traumatic event(s) by experiencing flashbacks, nightmares and other unwanted intrusive memories and thoughts.
Arousal, avoidance and re-living are all typical responses to a single trauma. EMTs are likely to experience multiple traumatic events throughout their careers, ultimately escalating their experiences into complex PTSD, accompanied by feelings of worthlessness, guilt, anger, emotional dysregulation, and relationship problems.11 The latter set of symptoms together with the sleep disturbances mentioned earlier are all common risk factors in developing depression and substance use disorders (SUD), not to mention the potential for trauma to trigger any latent mental health issues to which individuals may be predisposed by heredity or prior environmental factors.
Substance use disorder is another particularly insidious behavioral concern that is difficult to discern in oneself and in others, especially if a culture of drinking is present in the workplace or after hours. The phenomena of tolerance and dependence are two of the most significant indicators that alcohol and drug use has escalated beyond what is colloquially referred to as “heavy”, “problematic” or “disordered.”
Tolerance is related to the both the frequency and the volume of substance that one ingests: over time an individual may require more of the substance to generate the desired effect. SUD can be understood as an increasing “˜need’ for an individual to use the substance. To call this a “˜need’ is to suggest that the individual is experiencing withdrawal, discomfort that is associated with the absence of the substance or presence of various emotional or physical triggers.
To an individual with SUD, withdrawal symptoms can only be relieved by consumption of that substance in order to resume a sense of “˜normalcy’ or homeostasis. Drugs often interfere with homeostasis, where the person is feeding their addiction by continuing to utilize these substances in order to avoid having withdrawal symptoms
Tolerance, dependence, substance use on the job, and withdrawal may manifest in an individual’s observable cognitive, emotional and physical presentation. For instance, all of these are often warning signs that co-workers might identify with: regularly arriving late to work, smelling of alcohol or marijuana, red eyes, sweating, tremors, fatigue, cognitive symptoms such as low concentration or difficultly with comprehension, slurred or slowed speech emotional outbursts.
Over time you may notice the individual is isolating more than usual, or there may be evidence of problems in familial or romantic relationships. Outspoken denial of having an issue is often an indicator, but perhaps the most obvious clue is an individual’s tendency to continue using the substance even after expressing remorse, regret or other negative consequences relating to their substance use.
These indicators are not all that different from those presented in individuals with PTSD and depression, disorders which frequently co-occur with substance use. Given that substance use, PTSD and depression commonly contribute to death by suicide, the abovementioned indicators and warning signs are essential to saving the lives of the men and women that dedicate their lives to saving us.
First Responders, Mental Health and COVID-19
Being on the frontline is an everyday experience for first responders, but during this unprecedented state of pandemic emergency medical service providers are placed at extreme risk, not only for contracting the virus but for various mental health distress. Members of the first responder workforce are not immune to the economic downturn and may fear job loss for themselves or family members. The increased volume of callouts during COVID-19 leaves little room for recovery between potentially traumatic events and reduces opportunities for first responders to enjoy socializing with peers, in turn forcing social isolation to compound the effects of other anxieties.12
For those first responders that may already be struggling with substance use disorder, access to drugs may change due to the relaxed prescription regulations due to COVID-19.13 As with any person who is living with substance use disorder, this pandemic has altered their access to drugs: low supplies and surging prices of illicit or street drugs, as well as infrequent visits to physicians to dispense medicated assisted treatment for substance use disorder, or limited access to psychiatrists to refill antidepressants or anxiolytics.
Further, access to support groups is limited and while telehealth remains an operational substitute, behavioral therapy may not be all too accessible to the overworked, underpaid first responder. Longer shifts could mean a higher likelihood of exhibiting withdrawal symptoms on duty, or indeed a higher risk of using drugs or alcohol while on duty to avoid those withdrawal symptoms. The psychological impact of triage situations is difficult under normal circumstances.
But, if EMS providers are discouraged from taking drug overdose survivors to the emergency room, if attempted suicides are not prioritized because of the ER backlog, or if a psychotic patient requires means for restraint that are not available because of space or supply shortage — those providers may be exposed to a completely new range of stressors and triggers.
Strategies and Resources
For those providers that recognize and want to act on mental health and substance disorders, there are multiple strategies. Treatment for both conditions often include counseling, group therapy and medications. An often underutilized and underrated resource is the range of local peer recovery organizations. Recovery centers are aware of local treatment, group meetings and many
other resources. It is also important to focus on personal health and hygiene strategies: getting a good night’s sleep, finding alternative outlets outside of work, developing new hobbies, exercising daily and eating right.
It is also vital to maintain relationships and build social connections with friends and the community. Mental health and substance use disorders are often associated with individuals isolating themselves and disconnecting. Conversely, connection and relationships serve as protective factors against developing these issues. Asking your friends or loved ones for support is a good first step.
Pervasive stigma and codes of silence among first responders are perhaps the most prominent obstacle to seeking help and finding adequate support. Our experience is that some EMS providers do not trust their employee assistance programs with such confidential information, let alone risk being seen entering an office associated with the need for behavioral support. It is essential, then, that we make available and visible those resources directed at first responders, which are sensitive to these particular fears. For those who need help, or individuals who may be concerned about their loved ones or peers’ behavior, there are a number of excellent, confidential resources, including SAMHSA’s www.findtreatment.gov site that can help identify local treatment resources.
Here at the University of Texas Health Science Center at Houston (UTHealth), we have designed and implemented a short virtual training program specifically for first responders, describing how to recognize mental health and substance use issues in oneself or ones’ peers. We have also established a statewide, completely confidential toll-free helpline (833-EMS-IN-TX) to provide screening, brief interventions, motivational interviewing, and referrals to treatment. Other states have similar programs.
Recognizing the signs and symptoms of these disorders is essential, but even more imperative is taking the next step and seeking help. Especially during these stressful COVID-19 times, it is more important than ever to take care of yourself as much as you do your patients.
- Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health(2019) in HHS Publication No. PEP19-5068, NSDUH Series H-54. Retrieved August 2nd, 2020, from Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration https://store.samhsa.gov/sites/default/files/d7/priv/pep19-5068.pdf.
- First Responders: behavioral health concerns, emergency response, and trauma (2018) in Disaster Technical Assistance Center Supplemental Research Bulletin. Retrieved July 13th, 2020, from Substance Abuse and Mental Health Services Administration https://www.samhsa.gov/sites/default/files/dtac/supplementalresearchbulletin-firstresponders-may2018.pdf.
- Abbot, C., Barber, E., Burke, B., et al. (2015). What’s killing our medics? Ambulance Service Manager Program, in Reviving Responders. Retrieved June, 2020, from https://reviving-responders.squarespace.com.
- Vigil, N., Grant. A., Perez, O., et al. (2019). Death by suicide–The EMS profession compared to the general public. In Prehospital Emergency Care. 2018, 23(3): 340-345.
- Bentley, M. A., Crawford, J. M., Wilkins, J. R., et al. (2013). An assessment of depression, anxiety, and stress among nationally certified EMS professionals. In Prehospital Emergency Care, 17(3): 330—338.
- Stanley, I.H., Hom, M.A., Joiner, T.E. A systematic review of suicidal thoughts and behaviors among police officers, firefighters, EMTs, and paramedics. In Clin Psychol Review. 2016, 44(1): 25-44.
- Haddock, C.K., Poston, W.S.C., Jahnke, S.A., et al. Alcohol use and problem drinking among women firefighters. In Women’s Health Issues. 2017, 27(6): 632—638.
- Jones, S., (2017). Describing the mental health profile of first responders: A systematic review. In Journal of the American Psychiatric Nurses Association, 2017, 23(3): 200—214.
- Kleinewiese, J., Graeff, P. Ethical decisions between the conflicting priorities of legality and group loyalty: scrutinizing the “code of silence” among volunteer firefighters with a vignette-based factorial survey. In Deviant Behavior, 2020 ISSN: 0163-9625 (Print) 1521-0456 (Online) Journal homepage: https://www.tandfonline.com/loi/udbh20.
- Marshall, G.N., Jaycox, L.H., Engel, C.C., et al. PTSD symptoms are differentially associated with general distress and physiological arousal: Implications for the conceptualization and measurement of PTSD. In Journal of Anxiety Disorders. 2019, 62(1): 26-34.
- Lewis-Schroeder, N.F., Kieran, K., Murphy, B.L., et al. Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues. Harvard Review of Psychiatry. 2018; 26(4): 216-227.
- Baldi, E., Sechi, G.M., Mare, C., et al. COVID-19 kills at home: the close relationship between the epidemic and the increase of out-of-hospital cardiac arrests. In European Heart Journal. 2020; 41(32): 3045-3054.
- McDermott, W., March 25, 2020. DEA Policy: COVID-19 Prescribing Guidance (Effective March 31, 2020), in U. S. Department of JusticeDrug Enforcement Administration. Retrieved on September 2nd, 2020, from https://www.deadiversion.usdoj.gov/coronavirus.html.
- DEA (2020) U. S. Department of Justice Drug Enforcement Administration, https://www.deadiversion.usdoj.gov/coronavirus.html
- DEA Policy:”¯COVID-19 Prescribing Guidance“¯(Effective March 31, 2020)
- DEA Policy:”¯Registrant Guidance on Controlled Substance Prescription Refills“¯(Effective March 21, 2020)
- DEA Policy:”¯Exception to Separate Registration Requirements Across State Lines“¯(Effective March 25, 2020)
- DEA Policy:”¯Exception to Regulations Emergency Oral CII Prescription“¯(Effective March 28, 2020)
- DEA Guidance:”¯Q&A Remote Identity Proofing EPCS at hospital/clinics.
- Texas House Select Committee on Mental Health Interim Report to 85th legislature, Report on Mental Health Access for First Responders as Required by House Bill 1794, 85th legislature, Regular Session, 2017. https://hhs.texas.gov/sites/default/files/documents/laws-regulations/reports-presentations/2018/hb1794-mental-health-access-first-responders-dec-2018.pdf.