Abstract
Background: First responders’ stressful jobs can lead to an increased risk for mental health challenges, such as depression, anxiety, post-traumatic stress disorder (PTSD) or alcoholism. We explored how job duties affect the mental health of first responders and an employer’s role in providing preventive care and treatment.
Methods: We surveyed 433 first responders using a novel 35-question online survey. Descriptive statistics were calculated to describe our findings.
Results: Many respondents reported actively seeking treatment for mental health challenges; however, several reported having thought about seeking treatment. Participants reported the use of alcohol as a coping mechanism and indicated withholding information relating to a diagnosis from their employer for fear of losing their job or being unfit for duty.
Conclusions: Employers should support first responders’ mental health needs. Further research is needed to assess the impact of employer-based mental health programs.
Keywords: first responder, mental health, anxiety, depression, PTSD, suicidal ideation, alcoholism
First responders are expected to prepare for, respond to and mitigate serious situations they often cannot predict, which can lead to lingering mental health challenges (e.g., depression, anxiety, post-traumatic stress disorder, suicidal ideation and alcoholism) on and off the job.1
Understanding the barriers that exist in seeking assistance for mental health challenges is vitally important. Unfortunately, organizations may not always have defined policies and procedures to assist in the treatment of mental health conditions experienced by their personnel. As emergency responders work diligently to ensure they are prepared to meet the needs of the community, organizations must also take the same initiative to ensure they are doing what they can to meet the needs, including the mental health needs, of their personnel.
First responders often find themselves suffering internally from difficulties associated with mental illness due to on-the-job incidents that have influenced their overall mental state. These on-the-job stressors are directly related to poor mental health outcomes of first responders2 and can lead to an increased risk of depression, anxiety, post-traumatic stress disorder (PTSD) and suicidal ideations.3
Therefore, ensuring a first responder’s physical and mental readiness is imperative to increasing resilience4 against developing future mental health issues.
This study focuses on police officers, emergency medical technicians, paramedics and firefighters. Understanding the effects of a first responder’s job description and duties, and the associated impacts on mental health will aid organizations in identifying ways to address their personnel’s mental health. Due to the lack of literature on this topic, our study will expand upon current literature while bridging the gap with previous literature. Understanding the importance of mental health screenings is a vital component of ensuring the readiness of first responders to respond to calls for duty.
Encouraging personnel to have open dialogue relating to mental health is a key component to reducing the stigma often correlated to the term while promoting the realization that it is “OK not to be OK” and to seek help. Furthermore, while some agencies offer annual physical health screenings for their personnel, mental health screenings are rarely included as part of this effort. Findings from this study may lead to more agencies conducting annual mental health screenings for their employees resulting in improved mental health and well-being of first responders.
The purpose of this study was to examine the effect of job duties on the long-term mental health of first responders (i.e., police officers, correction officers, emergency medical technicians, paramedics and firefighters) and identify an organization’s role in providing mental health screening and treatment for job-related illnesses.
Methods
Participants were selected for the study based on certain inclusion criteria. They had to be working full-time as a firefighter, prison or corrections officer, EMT or paramedic. They had to have a current professional certification in their field and be older than 18 years.
All were welcome to participate in the study, no matter their gender, sex, religion or ethnicity. Approval from the A.T. Still University Institutional Review Board was received before the commencement of data collection. Study participants must have been able to read English fluently to complete the survey competently.
Invitations to participate in the study were sent to approximately 1,300 first responders. The survey was distributed through each agency’s online training platform and was deployed using the Qualtrics online survey platform. Data collection continued for ten weeks, with reminder emails for participation distributed during weeks three and six.
Survey Development
A novel survey was developed that included items to gather demographic information and data on the occupation of first responders. The demographic information collected included sex, race, occupation, highest education achieved, marital status and years of experience. The remaining survey questions were designed to gain an understanding of whether the first responders had a history of or were having symptoms associated with depression, anxiety, post-traumatic stress disorder (PTSD), suicidal ideation, or alcoholism.
Additionally, participants were asked whether they had used alcohol as a coping mechanism to deal with events witnessed as part of their job, as well as whether they have ever avoided disclosing information associated with mental illness or alcoholism for fear of losing their job or being found unfit for duty.
A few questions then addressed whether a survey respondent’s employee offered psychological testing as part of an annual physical, and whether the respondent would be interested in participating in an annual psychological assessment or mental health screening, if their employer offered one.
Two open-ended questions were included at the end of the survey. One question allowed participants to identify, if they chose, what needs are currently not being met by their agency regarding mental health awareness and treatment.
The second question gave respondents an opportunity to share what advice they would offer to their senior leadership to ensure a proactive approach toward ensuring the mental health of their personnel is being met.
Results
Thirteen hundred first responders were invited to complete the study survey regarding the mental health of first responders. Of those invited to participate, 634 were either firefighters, EMTs, and/or paramedics (48.7%), 370 were police officers (28.5%), and 296 were corrections officers (22.8%).
Four hundred and thirty-four respondents (33.38%) participated in the study; however, one respondent was excluded due to responses that were extreme, infeasible outliers, thereby resulting in a sample size of 433 (N=433).
Sample Characteristics
Table 1 summarizes the pertinent characteristics of this study group, including age, sex, race/ethnicity, occupation, educational level, and years of service. Three hundred and twenty-seven participants identified as either a firefighter/EMT or a firefighter/paramedic (75.5%), while 91 were police officers (21%). Four respondents identified as corrections officers (0.9%), while one identified as a single-certificate paramedic (.2%), and the other as a single-certificate EMT (.2%).
Eight individuals refused to identify their occupation (1.8%). Most survey participants were male (n=388), with 36 female participants responding to the survey. Three individuals identified as non-binary. Most respondents were Caucasian (88.5%), followed by Black/African American (0.9%), and Native American or Alaska Native (0.9%). Thirty-three (7.6%) participants identified as an “Other” race, most typically Hispanic, Latino, or a combination of the two. The remaining participants identified as Asian (0.5%), Native American, and/or Pacific Islander (0.2%).
The respondents’ professional characteristics are summarized in Table 1.
The percentage of first responders who held either a high school diploma or a certificate from a trade/technical school was 43.0%. The number of respondents with an associate degree was 31.4%, while 18.7% reported earning a bachelor’s degree.
Respondents who have earned an advanced degree included 5.3% for a master’s degree and 0.2% for a Doctoral degree. The average tenure of the respondents working as first responders was 14.37 years, with a minimum value of two months and a maximum value of 40 years.
Description of Result
Findings related to the number of first responders who have either sought treatment, thought about seeking treatments, and/or currently receiving medications for either depression, anxiety, PTSD, or suicidal ideation are summarized in Figure 1.
The results relating to the use of alcohol as a coping mechanism are displayed in Figure 2.
Finally, understanding the number of personnel who withheld information from their employer in fear of losing their job or being unfit for duty is displayed in Figure 3.
Figure 4 summarizes participants’ responses about the availability of mental health screenings as part of their regular job duties (outside of an employee assistance program –[EAP]).
Figure 5 represents responses from participants who worked 24-hour shifts (firefighter/EMTs and firefighter/paramedics) (n=327) who reported how many hours of sleep they had received on average (while on shift) in the previous 30 days.
Most (62%) respondents reported getting 2-6 hours of sleep per 24-hour shift. Responses to the two open-ended questions in the survey are addressed in the Discussion section.
Finally, respondents were asked to select which group they would be most comfortable seeking treatment for a mental health concern. The available options included a personal health care provider, an employer’s EAP, an agency-sponsored health care provider, the International Association of Fire Fighters (IAFF) Center for Excellence for Behavioral Health Treatment, and the Florida Police Benevolent Association or a closely related entity.
Specific centers would apply only to a particular occupation, so realizing the overall percentage of survey respondents’ occupations is essential when one is analyzing these data. The results are displayed in Figure 6.
Discussion
In this study, the most frequently reported and sought-after treatment was for depression, closely followed by anxiety and PTSD. Suicidal ideation lags behind the other diagnoses, although the response rate still proved troubling. These findings are supported by previous research that proved that at least 30% of first responders would experience symptoms related to stress, anxiety, and depression (SAD) as part of their job function.5
When examining the most common mental health condition that first responders thought about seeking treatment for, depression was the leading indicator, closely followed by PTSD and anxiety. Again, suicidal ideation lagged in the number of confirmed responses, although one may argue that any individual suffering from these ideations is troubling.
Additionally, these findings are supported by previous research by Stanley et al.,6 who examined pre-career rates of suicidal ideations versus ideations experienced while on the job in 313 female firefighters and found that married firefighters were significantly less likely to report career suicide ideations.
Nearly one-third of the current study’s respondents admitted to using alcohol as a coping mechanism, while 8% of respondents admitted to intentionally withholding information relating to alcoholism from their employer in fear of losing their job or being found unfit for duty.
These data are further supported by research proving alcohol can often be a mechanism to deal with occupational stress.7. Furthermore, Irizar et al.8 found that 21.6% of first responders reported using alcohol as a coping mechanism to deal with traumatic incidents witnessed in the occupational setting.
The withholding of information from employers included, not only the withholding of alcohol consumption, but also a more substantial percentage of respondents not disclosing information relating to depression, anxiety, PTSD and suicidal ideation. Ensuring employees are comfortable seeking help for mental health is vitally important to ensure their longevity in the workforce in a healthy state of mind.
Study results showed that many respondents believed their employer should offer a psychological assessment, with an even greater response of respondents that agreed that they would participate in receiving a regular psychological assessment. These data represent the need and desire for mental health assessments and show a positive trend toward understanding that mental health is as essential as a physical health assessment.
Employers should reflect on these data and other research data and strive to understand their role in ensuring the health, safety, and wellness of their first responders.
The open-ended questions at the end of the survey inquired about needs currently being unmet by a respondent agency regarding mental health awareness and treatment, and any advice a respondent would provide to their senior leadership to ensure a proactive approach toward ensuring their personnel’s mental health was met.
The most common theme identified from the responses to the question regarding unmet agency needs was the lack of annual mental health physicals/assessments offered by the department and the high unit-hour utilization of units (fire-rescue), resulting in sleep deprivation and burnout. One respondent (firefighter) commented:
“…unit-hour utilization is too high, causing poor attitudes and disgruntled employees, and decreases the ability to maintain good mental health. A 24-hour schedule is also difficult to deal with on busy days when you end up working 27-28 hours with no sleep due to the call volume. Getting hit for mandatory overtime of 24 more hours after that, to continue being at another busy station, not only makes it difficult to maintain mental health but also makes me want to quit this career altogether.”
Another respondent (firefighter) commented:
“…mental health should be as important as physical health. Easier access to mental health counseling specific to first responders.”
A less common theme included looking for ways to reduce the stigma that seeking mental health treatment is a sign of weakness. Some respondents offered ideas on improving mental health, including “focusing on the promotion of physical health, and including annual physical agility tests.”
Another theme presented was that employees need to work 30 years in this career to receive a full pension. Thoughts were shared that this 30-year career timeframe should be reduced, due to the amount of tragedy often witnessed in a career that long.
Responses to the second open-ended question included the following, “Captains and supervisors may need training on early detection of mental illness” and “I would like some more teambuilding activities to help bond crews together.
At the end of the day, your crew is the only thing that will keep you sane with some of our calls.” The establishment of a safe culture where open communication can occur, regarding mental health, appears to be desired by respondents.
Limitations
CISM/Peer Support Coordinator Joseph Coleman regarding mental health.
Study participants were recruited through their respective agencies’ online training platforms and were asked to complete an anonymous online survey. One limitation of this study was the relatively low proportion of police officers and corrections officers that participated in this study. In addition, during the data collection phases of this study, correspondence was released that the Sheriff’s department was giving up control of the county detention center and turning over control to the county.
This action resulted in nearly 300 sworn corrections officers being made aware that they would be losing their designation as a “sheriff’s deputy” and ultimately placing them into a county organizational structure within a few months. This had the potential to lower morale among this correctional staff, which may have also contributed to the low response rate of corrections officers.
One consideration is the lack of computers in the correction officer’s immediate work areas may have impacted survey participation. Another limitation of the study was the security placed on the Sheriff’s office computers, making opening some attachments and links difficult, mainly when they originate from outside the agency.
Another limitation of this study was that the researchers could not silo the respondent’s answers based on their selected profession. This information could have allowed the researcher greater insight into mental health issues relating to a specific occupation.
For example, understanding whether firefighters who work 24-hour shifts have a greater incidence of a mental health disorder that could potentially be related to sleep deprivation. Although, due to the low response rates from some occupations, this could have made anonymity more challenging if occupations were separated as part of the survey.
One survey question seemed to have caused confusion and may have required further clarification. For example, the question asked whether the respondent’s employer provided an annual psychological assessment, and 215 respondents stated that their employer did. Because fire-rescue had the greatest number of participants, many of these responses likely included fire-rescue employees.
However, fire-rescue does not currently include annual psychological assessments as part of their annual physicals. Respondents may have been confused, thinking that peer support services, such as Critical Incident Stress Management (CISM) or Employee Assistance Programs (EAP), could be counted towards this response. Even though the survey questions delineated that an Employee Assisted Program should not be considered in answering the survey question, it appears that this may have been overlooked.
Recommendations
Occupation-specific, directed research may provide valuable information regarding the specific needs of an individual agency. For example, research should be conducted to examine the effects of treatment on the mental health, including depression, anxiety, PTSD, suicidal ideation and alcoholism, of first responders.
Employer-provided annual assessments may be the impetus to ensuring our emergency responders’ overall mental health and wellness, thereby giving them the knowledge, skills, and abilities to cope with the emotions incurred as part of their job responsibilities.
Future qualitative and quantitative research would be beneficial to expand on this subject matter further. Descriptive and causal research designs can provide valuable data regarding the effects of mental health treatment of first responders.
Conclusion
Our results showed that emergency responders could face challenges relating to anxiety, depression, PTSD, suicidal ideations, and alcoholism throughout their careers. Providing support that considers a first responder’s physical, emotional, social, and spiritual well-being can be instrumental in ensuring the health and well-being of a first responder.
Because of the high-stress environment in which first responders work, long work hours, and the potential for sleep deprivation, organizations must provide a framework to care for the mental health of their personnel. Many first responders receive annual physicals that include, for example, cancer screenings, cardiovascular testing, and bloodwork, although many go without a mental health assessment. Understanding that an annual mental health assessment is as essential as an annual physical health assessment is vital to ensuring our first responder’s health, safety, and wellness.
Including pre-hiring mental health assessments can set a foundation for an employee and employer to monitor mental health status. With ongoing annual mental health assessments, trained mental health practitioners can monitor a first responder’s mental health status and prescribe additional therapy. First responders need to remember that it is okay, not to be okay, and be willing to seek assistance.
References
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