Taylor Shearer reviews mental health issues in EMS, its factors and offers suggestions on how to better manage mental well-being.
Introduction
More than half a century has elapsed since the first International Congress of Mental Health was constructed in 1948.1 Since then, great progress has been made in the field of mental health education, resulting in a greater acceptance and understanding of mental illnesses and their potential consequences. Despite these advancements, the emergency medical services (EMS) community has remained among some of the highest rates of occurrence of mental illness paired with some of the lowest likelihood of seeking treatment.2 This text is designed to review the occurrence of mental health issues among EMS personnel, factors that contribute to this phenomenon, and suggestions for how to better manage EMS providers’ mental well-being.
It is no secret that an occupation within EMS results in a high-stress work environment. In addition to general job-related stressors; poor sleep schedules, and repeated exposure to hazards and tragedy all contribute to the association between EMS personnel and the occurrence mental illness. Foundationally, the greater EMS community is largely driven on pride and the need to maintain a strong and unphased demeanor. This desire to possess such a resilient appearance stems from fear of being perceived as weak or incapable providers by their colleagues and superiors. Collectively, these factors create an environment in which the involved personnel are at an increased risk for developing mental illnesses yet have the tendency to not act on their deteriorating health.
Related
- Suicides Affect Patients & EMS Providers
- Don’t Let Me Down: First Responder Suicide
- The Ready Room: Clinician Suicide
The long-waged war between EMS providers and dismissal of their own mental health needs is grim in nature. In the United States, death by suicide is a leading cause of premature deaths of EMS personnel; second only to death by motorized vehicles during responses occurring on roadways.3 As alarming as this single statistic is, it is not a new finding; it has been relevant for decades. Yet, the EMS community has continued to maintain the same trajectory regarding this subject matter with little to no substantial improvements visible. Until this cohort begins acting upon this daunting reality, the community will continue to fall victim to tragic demise at the hands of mental illness.
The Prevalence of Mental Illness in Emergency Medical Services
Nationwide, there is a significantly increased rate of depression, anxiety, fatigue, sleep disorders, post-traumatic stress disorder (PTSD), and suicidality among EMS workers than the general public.4 An anonymous survey conducted in 2017 aimed to evaluate the potential risk of future suicidal behavior among 903 prehospital providers. This survey included 20 different EMS agencies; spanning urban, suburban and rural settings. The survey was constructed with the use of the Suicidal Behaviors Questionnaire-Revised (SBQ-R), in addition to questions regarding demographics, EMS experience and relevant medical history.
The SBQ-R breaks down questions to encompass the four dimensions of suicidality: lifetime suicidal ideation and/or attempt, frequency of suicidal ideation over the past 12 months, threat of future suicide attempts, and the likelihood of suicidal behavior in the future. A SBQ-R score of seven or greater is considered a valid predictor for an increased risk for future suicidal behavior. Results collected from the 2017 anonymous survey revealed that 31.3% of the respondents had an SBQ-R score of greater than seven. Of the 903 EMS providers included in the survey, 27.2% reported experiencing at least one suicidal ideation in the past year; a rate that is seven times higher than the average population.5
Currently, it is estimated that approximately 20% of adults within the general United States population will experience a period of mental illness at some point within their lives. That occurrence rate increases to approximately 30% among EMS personnel.6 This data reveals the large prevalence of mental illness among EMS providers, however many of these individuals conceal their struggle with mental health, thus going untreated. Experiencing a prolonged episode of decline in mental health has a direct correlation with the likelihood of completing a suicide attempt.
Data pulled from the Arizona Vital Statistics Information Management System Electronic Death Registry regarding all adult deaths between 2009-2015 revealed suicide rates among EMS personnel to estimate around 5.2% while non-EMS death by suicide occurred at a rate of approximately 2.2%.7 Information from these studies pertaining to mental illness among EMS providers confirms that these are not random situations, there is clear cause for the occurrences.
Contributing Factors
Universally, the top three stressors contributing to a poor state of mental health include; career, finances, and lack of sleep.5 When considering the length of shifts, standard wages, and situational exposures, it is unsurprising that workers in EMS would be considered to be high risk for developing a form of mental illness.
Every EMS agency operates under their own specific schedule and policy for shift length and rotation of shifts. Commonly, many agencies utilize a timeframe of 12, 16 or 24-hour shifts. Depending on call volume and occurrence, there is an inevitable alteration to providers’ circadian rhythm. This prevents the establishment of a healthy, regular sleep cycle for these individuals.4 In addition, many providers seek overtime hours outside of their normally scheduled shifts or are employed with multiple agencies resulting in working back-to-back shifts. This is largely reported due to the pay discrepancy within the EMS community; many providers reveal feeling as though the additional hours worked are a necessity to obtain a comfortable financial standing. While both sleep disturbances and financial concern are products of a career within EMS, the largest stressor contributing to an increased risk of mental illness is pinned to the nature of the occupation itself.
EMS workers are regularly exposed to the realities of human sufferings and tragedy; including death. There is an inherent nature of unpredictability within the occupation emphasizing the need for providers to possess the ability to focus their attention and continue to perform in situations of high psychological pressure. Providers have the tendency to fall victim to moral injury following a tragic call, succumbing to feelings of guilt and even shame when they are unable to successfully treat a patient’s condition.4 These direct occupational stressors can be grouped into three general categories: routine work demands, critical incidents involving serious harm or death, and social conflicts.
Within a given workday, each additional work demand or critical event encountered results in a 5% increase in PTSD symptom severity for that day and the days immediately following. Additionally, a 12% increase in severity of depression symptoms is observed in association with each additional social conflict experienced pertaining to their occupation.8
Unlikely to Seek Help – Why?
Many affectionately refer to EMS providers as “adrenaline junkies,” referring to the natural release of catecholamines that occurs when the fight-or-flight sense is stimulated upon response to an emergency event. However, Dr. Jeffery Mitchell reveals a more specified list of commonly seen traits that are characteristic of emergency personnel. These traits include, a need to be in control, obsessive, highly internally motivated, easily bored, a strong demand to be needed, risk takers, action-oriented, high need for stimulation and immediate gratification, and highly dedicated.9 Considering this list, it becomes evident that individuals within this profession typically have strong personalities and are self-motivated in pursuit of successful outcomes. This results in the production of an intrinsic sense of ego and pride that one must uphold in order to feel adequate among their superiors and colleagues.
This internal image of pride is, in large, the common denominator as to why EMS workers fail to disclose personal difficulties with their mental health.10 A survey was conducted by the University of Phoenix regarding the reasons why prehospital providers fail to report their own mental health decline. The results of this survey revealed that if they were transparent about their mental health struggle, approximately 55% of providers feel their superiors would treat them differently, 45% report their coworkers would see them as weak, and 34% of the individuals feel that this knowledge may hinder promotion potentials in the future.9
Opportunities for Improved Mental Health Care
In order to change the trend of providers failing to seek care for mental illness, there first must be an alteration that occurs pertaining to how the EMS community perceives and engages with mental health issues regarding themselves and coworkers. An initiation for change can be implemented through the steps of ensuring EMS personnel are properly educated on mental health, removing the barriers to seeking help, and creating facilitators to obtaining help.11
Proactive education regarding available mental health resources allows providers to know where to turn for help before they actively need to seek help. This encourages personnel to stay ahead of their own mental health battle and have a plan-of-action established before the need for help becomes an urgent matter. Education regarding mental health and illnesses specific to the occupation of EMS also promotes an environment for healthy realizations to occur. As previously discussed, pride and self-worth are of great importance to prehospital healthcare workers. If these individuals believe that they are alone in feeling that their mental health is affected by their occupation they are more likely to resist the urge to seek outside assistance.
However, every traumatic situation will provoke a different trauma response in each provider affected. Meaning that within the same traumatic event, providers may experience no impact from the exposure, others may experience a profound impact, and some may not have an immediate impact, but rather an addition to cumulative trauma.7 This knowledge base creates an understanding that some providers may be more greatly impacted than others by specific events, and that this variation of provider trauma responses is a normal occurrence.
Removing the barriers and facilitating workers to seek help often occur simultaneously. Essentially the goal is to remove the inhibitor while introducing an enabler. This should be implemented beginning with the foundational barrier within the EMS community, removal of the negative stigma pertaining to providers seeking mental health assistance.12 This barrier, fueled largely by the pride encompassed by EMS personnel, establishes a feeling of weakness when experiencing a mental health decline; as if the individual failed at their job. By removing this obstacle there is an environmental shift towards normalizing mental illness experienced by providers.3
Some obvious facilitators to seeking assistance for mental health issues include attending therapy and starting a pharmaceutical regimen. Interpersonal support, a lesser discussed facilitator, is a largely adventitious tool in managing one’s own mental health.12 EMS providers know how to protect each other, but don’t know how to help one another.10 By promoting an environment that encourages providers to support each other, traumatic events are addressed more readily resulting in a likely decrease in the severity of impact on the provider.7 Peer support is also beneficial in removing the pressure of seeking professional help by allowing the conversation to occur between individuals who are already acquainted.
Data shows that providers who seek to learn lessons from daily challenges are met with a 3% decrease of daily depression symptoms. This self-assessed approach encourages an environment in which all calls have the opportunity to become learning experiences. By self-evaluating the areas in which EMS personnel excelled as well as areas of improvement following a call, the provider is able to create a learning opportunity for themselves. Decompressing from especially trying calls by searching for growth opportunities has proven to be largely successful.13
Recognition of conflict and challenges serves as a tool to learn and improve as a provider. Along with recognition, it is crucial to reflect and build upon the communication strategies utilized during difficult calls, promoting another avenue for providers to better understand the situation in its entirety. Ultimately, there is no substitution for needing to recharge following a traumatic call. EMS providers should take a proactive approach when faced with high-stress circumstances involved with emergency calls, by voicing their need to have a moment to step away and seek mental clarity.8
Conclusion
Mental illness has ravaged personnel within the EMS community since its origin; a trend that will continue occurring until change is enacted. EMS personnel are predisposed to mental illnesses due to high-stress environments, repeated exposure to morbid events, and lack of a structured sleep schedule. This predisposition is well known yet resisted to accept within an industry so heavily influenced by pride and interpersonal judgement. This norm of mental health ailment can be acted upon, providers can be better helped, and EMS personnel suicide rates can be decreased.
To see motion with this progression the underlying factors must be brought to light and seen though an honest viewpoint. Providers should be encouraged to seek treatment should they experience a mental health decline. Likewise, providers should be encouraging their colleagues to seek help. The EMS community excels at defending their own but fails to know when to help their own. Implication of resources that assist in bettering providers’ mental health while still maintaining their dignity is crucial to the success of improvement of mental health in this field.
The EMS community is comprised of driven individuals who dedicate their lives to rendering care to the public in the event of a medical emergency. It is of equal importance that these personnel offer the same dedication to themselves and their colleagues when assessing and caring for their mental health.
References
1. BERTOLOTE J. The roots of the concept of mental health. World Psychiatry. 2008;7:113-6. doi: 10.1002/j.2051-5545.2008.tb00172.x. PubMed Central PMCID: PMC2408392.
2. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Substance Abuse and Mental Health Services Administration (US). 2022 [cited February 10 2022]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t30/.
3. Chris G. Caulkins M, MA, ABD. Psychological Trauma: The Silent Stalker. JEMS: Journal of Emergency Medical Services. 2018.
4. Awais SB, Martins RS, Khan MS. Paramedics in pandemics: protecting the mental wellness of those behind enemy lines. The British Journal of Psychiatry. 2021;218(2):75-6. Epub 2020/10/23. doi: 10.1192/bjp.2020.193.
5. Al Lulla M, MS; LinLin Tian, MD, PhD; Hawnwan Philip Moy, MD; Kristen Mueller, MD; and Bridgette Svancarek, MD. CE Article: The EMS Suicide Threat2020 February 2020. Available from: https://www.hmpgloballearningnetwork.com/site/emsworld/1223779/ce-article-ems-suicide-threat.
6. James Langabeer P, EMT, Meredith M. O’Neal, MA, Simone Joannou, MA Recognizing and Supporting EMS Providers with Mental Health and Substance Use Disorders
. JEMS: Journal of Emergency Medical Services. 2020.
7. Vigil NH, Grant AR, Perez O, Blust RN, Chikani V, Vadeboncoeur TF, et al. Death by Suicide-The EMS Profession Compared to the General Public. Prehosp Emerg Care. 2019;23(3):340-5. Epub 20180914. doi: 10.1080/10903127.2018.1514090. PubMed PMID: 30136908.
8. University S. EMS workers 3 times more likely to experience mental health issues [Peer-Review Publication]. EurekAlert!: American Association for the Advancement of Science; 2021 [cited 2022 February 25 ]. April 5, 2021:[Available from: https://www.eurekalert.org/news-releases/733519.
9. Wilson SMJ. EMS Provider Health And Wellness. StatPearls 2021.
10. Phillips L. Putting first responders’ mental health on the front lines. Counseling Today. 2020. Epub July 6, 2020.
11. Staff MC. Depression (major depressive disorder): Mayo Foundation for Medical Education and Research (MFMER); 2018 [updated February 3 2018; cited 2022 February 25]. Available from: https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007.
12. Sara Jones 1 KA, Jean McSweeney. Barriers and Facilitators to Seeking Mental Health Care Among First Responders: “Removing the Darkness”. J Am Psychiatr Nurses Assoc 2019. Epub September 11 2019. doi: 10.1177/1078390319871997.
13. Nina F Lewis-Schroeder 1 KK, Beth L Murphy, Jonathan D Wolff, Matthew A Robinson, Milissa L Kaufman. Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues. Harv Rev Psychiatry. 2018 216-27. doi: 10.1097/HRP.0000000000000176. PubMed Central PMCID: PMC6624844.
