What the Research Tells Us about Mental Health

First responders regularly confront high-stress incidents.^1,16 They are exposed to death in all forms and do not have the option of shying away. Instead, they must confront it head-on. These individuals are often exposed, for the first time, to these traumas while still undergoing their training and education.

Current research provides evidence of high rates of depression, post-traumatic stress disorder (PTSD), and poor well-being among first responders.^1,5,8 Researchers universally attribute these higher rates of mental distress to the occupational hazards of the individuals. Aldrich and Cerel took the research a step further and examined the correlation between exposure to suicide and the mental well-being of first responders.¹

They found substantial exposure to suicide in the first responder population and a high prevalence of PTSD and depression. Suicide rates have increased considerably in the general population, and the prevalence of suicide increases in the first responder community.^3,15

For EMTs, the rate is 1.39 times more likely than the general population.⁵ For PTSD, 30% of first responders develop it at some point as compared to only 6% of the average American.^12,14

One study looked specifically at paramedic students and found the students who encountered death or experienced fear of making clinical mistakes were at risk for developing PTSD and unhealthy stress.¹⁶

First responders will commonly witness such tragedies before graduating from their programs. With such exposures being correlated to poor mental health in the future, these students, unfortunately, are starting their careers predisposed to long-term mental health issues.^5,16

Warren-James et al. identified another problem.¹⁶ They found that paramedic students form negative feelings towards displays of emotion. This problem is common in first responders and can lead to internalizing emotions and more substantial problems in the future.

Poor coping mechanisms, negative attitudes toward feelings, and the probability of exposure to critical incidents mean first-responder students are part of a cycle. This cycle contributes to professionals being ill-prepared to deal with their mental health, if they do not come to school with those skills.

Lawn et al. found the way management and the workplace culture handles work stressors, alongside coping mechanisms and the use of humor, makes an important difference in keeping paramedics mentally healthy.⁹

Lowery and Cassidy identify physical fitness as one of the main mediating factors for first responders regarding their mental health, alongside self-compassion and social support.¹⁰ This finding aligns with other researchers’ conclusions regarding physical fitness and stress.^2,4,14

For example, Smith and colleagues, in a study about how first responders coped after responding to the events on 9/11, found that exercise was one of the most reported mechanisms utilized by those who had responded to the attacks.¹³

Kohl and Hussain argue, compellingly, for similarities between athletics and paramedicine.⁷ They note how many skills learned as athletes translate into the ability to function as paramedics, such as performing under pressure, recognizing limitations, self-evaluation, and communication techniques. So, while there are many challenges for first responders in staying active, it is essential they do remain physically active and is well within the realm of possibility.^6,10,11

Speaking anecdotally, the last few years have been challenging for many colleagues of mine. Not only are there normal challenges of the job, but many districts are facing a shortage of qualified and quality individuals to fill their trucks, funding problems are abundant, and call volume continues to rise.

Unfortunately, these burdens fall, one way or the other, on the shoulders of those on the road. Unsustainable call volumes for the number of units on the road, mandatory overtime, and old equipment, trucks, and stations often contribute to the weight of this burden felt by first responders.

There is also a feeling of “keeping up with the Jones” with more and more districts adopting critical care protocols, using ultrasound machines, pumps, and advanced vents as well as community paramedicine, which all lead to equipment and training needs that may feel rushed or unsupported leading to poor training and preparedness of staff.

Not to say we should not be doing these things; however, we need to consider the staff already stressed at baseline and ensure these advances are rolled out appropriately.

A few years ago, I hit an incredibly low point. I saw multiple therapists, tried taking time off, and inevitably did what many of us first responders do, “sucked it up”. I was overworked, getting “mandatoried” while finishing my mandatory shift, not spending time with my family, my finances were depressing, and I had a call that still keeps me up at night years later.

Eventually, I changed jobs, transitioning to a paramedic instructor, where most of my woes disappeared. I miss being on the ambulance terribly and often think about going back. Looking back, I realized that my habits were not conducive to good mental health. I did not have a good workout routine; I ate poorly, I did not have an outlet at home, and I did not feel supported (I was, it is just difficult to see that while in it).

What does the research and my and other’s experience tell us? In short, we have a problem. Mental distress is widespread among first responders, with challenges such as depression, PTSD, and suicide being rampant.

The good news is that there are ways to cope. Tolkien says it best, “Courage will now be your best defense against the storm that is at hand – that and such hope as I bring.” Seeking counseling with a professional, especially one who works with first responders, is always a good starting point.

Besides that, staying physically active, having a robust social network of family and friends, and having a supportive work environment are all important. Many may be aware of the challenges among first responders. We are a stoic group who do not like asking for help. I always respected the older generation that would, as patients, say their pain was not that bad while their broken tibia was protruding out of their leg.

First responders tend to respond similarly to difficulties by consistently claiming they are fine when, in truth, their metaphorical tibia is sticking out. The original definition of a patient comes from 14^th century France and can be paraphrased as one who endures suffering without complaint, and this describes first responders, too!¹⁷

As C. S. Lewis once said, “I have learned now that while those who speak about one’s miseries usually hurt, those who keep silence hurt more.”

About the Author

Joe Haack, NRP, CP, MBA, is a program director for an EMS program in the Midwest. Joe works mostly with entry level providers and cares a great deal about preparing them for the future of EMS. Joe has a wife and five children. He cares a great deal about them too.

References

1. Aldrich R, Cerel J. Occupational Suicide Exposure and impact on Mental Health [Internet]. 2020 [cited 2024 Aug 6]. Available from: https://journals.sagepub.com/doi/10.1177/0030222820933019 Barney DC, Pleban FT, Lewis T. Relationship between physical activity and stress among junior high school students in the Physical Education Environment [Internet]. 2019 [cited 2024 Aug 5]. Available from: https://js.sagamorepub.com/index.php/pe/article/view/8966
2. Tanner J. Bommersbach M. National trends of mental health care among us adults who attempted suicide [Internet]. JAMA Network; 2022 [cited 2024 Aug 5]. Available from: https://doi.org/10.1001/jamapsychiatry.2021.3958
3. Cahuas, A., He, Z., Zhang, Z., & Chen, W. (2019). Relationship of physical activity and sleep with depression in college students. Journal of American College Health, 68(5), 557–564. https://doi.org/10.1080/07448481.2019.1583653
4. Eiche C, Birkholz T, Jobst E, Gall C, Prottengeier J. Well-being and PTSD in German Emergency Medical Services – a nationwide cross-sectional survey [Internet]. Public Library of Science; 2019 [cited 2024 Aug 5]. Available from: https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0220154
5. Jerome GJ, Lisman PJ, Dalcin AT, Clark A. Weight Management Program for first responders: Feasibility study and lessons learned [Internet]. IOS Press; 2020 [cited 2024 Aug 5]. Available from: https://content.iospress.com/articles/work/wor193069
6. Kohl A, Hussain A. A paramedic-athlete model for improving mental wellness and resilience in Canadian paramedicine [Internet]. 2021 [cited 2024 Aug 5]. Available from: https://eds-p-ebscohost-com.proxy.library.maryville.edu/eds/pdfviewer/pdfviewer?vid=3&sid=7657ef08-0b78-4230-9850-7f09c50ca14a%40redis
7. Kyron M, Rikkers W, Bartlett J, Renehan E, Hafekost K, Baigent M. Mental health and well-being of Australian police and emergency services employees [Internet]. 2021 [cited 2024 Aug 5]. Available from: https://www.tandfonline.com/doi/full/10.1080/19338244.2021.1893631
8. Lawn S, Roberts L, Willis E, Couzner L, Mohammadi L, Goble E. The effects of emergency medical service work on the psychological, physical, and social well-being of ambulance personnel: a systematic review of qualitative research. BMC Psychiatry. 2020 Jul 3; 20(1): 348. doi: 10.1186/s12888-020-02752-4. PMID: 32620092; PMCID: PMC7332532.
9. Lowery A, Cassidy T. Health and well-being of first responders: The role of psychological capital, self-compassion, social support, relationship satisfaction, and physical activity [Internet]. 2022 [cited 2024 Aug 5]. Available from: https://www.tandfonline.com/doi/full/10.1080/15555240.2021.1990776
10. Paakkonen H, Ring J, Kettunen J. Physical fitness of paramedic students during vocational training – a follow-up study [Internet]. 2021 [cited 2024 Aug 5]. Available from: https://www.researchgate.net/publication/323320863_Physical_fitness_of_paramedic_students_during_vocational_training_-_a_follow-up_study
11. SAMSA. First responders: Behavioral health concerns, emergency response, and trauma [Internet]. 2018 [cited 2024 Aug 5]. Available from: https://www.samhsa.gov/sites/default/files/dtac/supplementalresearchbulletin-firstresponders-may2018.pdf
12. Smith E, Walker T, Jr FMB. Lessons in post-disaster self-care from 9/11 Paramedics and emergency medical technicians: Prehospital and disaster medicine [Internet]. Cambridge University Press; 2019 [cited 2024 Aug 5]. Available from: https://www.cambridge.org/core/journals/prehospital-and-disaster-medicine/article/abs/lessons-in-postdisaster-selfcare-from-911-paramedics-and-emergency-medical-technicians/369465B936632EA6BBD233FA01CB4A71
13. U.S. Department of Veteran Affairs. Va.gov: Veterans Affairs [Internet]. 2018 [cited 2024 Aug 5]. Available from: https://www.ptsd.va.gov/understand/common/common_adults.asp
14. 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 [Internet]. U.S. National Library of Medicine; 2018 [cited 2024 Aug 5]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30136908
15. Warren-James M, Hanson J, Flanagan B, Katsikitis M, Lord B. Paramedic students’ experiences of stress whilst undertaking ambulance placements – An integrative review. Australas Emerg Care. 2021 Dec;24(4):296-301. doi: 10.1016/j.auec.2021.03.002. Epub 2021 Apr 2. PMID: 33814343.
16. Etymology. Patient (adj.) [Internet]. 2020 [cited 2024 Aug 5]. Available from: https://www.etymonline.com/word/patient