In 2017, approximately 115 emergency first responders died by suicide. Experts contend that this epidemic is associated with a variety of factors, one of which is access to mental health care. Rates of suicide have continued to grow since 2005, and rates of mental health challenges continue to rise as well.1 Yet, barriers in access to mental healthcare continue to exist, as an estimated 92% of firefighters report barriers to behavioral health treatments.3 As “strong mental health translates to improved public service,” yet there continue to be limited efforts to improve access to mental healthcare for first responders at the national level.3
Background
As first responders are a vital part of ensuring public safety and response, this population experience situations inherent in their jobs. However, this does not mean that these risks should be considered a normal part of the workday, or that they should not receive treatment for mental health challenges.10 These mental health challenges include a variety of conditions affecting mood, thinking, and behavior. While it is generally considered that there are many risk factors associated with these conditions, it is also generally accepted that seeking and receiving quality treatment is the foundation of maintaining well-being in the face of adversity. It has been reported that many first responders do not feel comfortable accessing services due to fear of retribution by an employer, which may be a more prominent response in a rural community.
Scope of the Problem
Mental health awareness has been a debate on the national stage for years, but little headway has been made in truly addressing the issues. The literature suggests that these issues are even worse for rural communities, reaching crisis level. While there has been an increased effort to provide enhanced mental health services, the services remain limited. Increased awareness does not necessarily translate to action.
On November 18, 2016, an American MedFlight plane crashed landed after takeoff in rural Elko, Nevada community, killing the flight nurse, paramedic, pilot, and patient on board. This was a devastating event for the community, fire department and first responders. The flight nurse was a member of the volunteer fire department, as well as prominent member of the Elko community. First responders on scene will never forget the overwhelming feeling of grief, yet dedication to duty they had in those moments. Following the tragedy, there were limited options and support available to the first responders and friends in the community. This is partly due to the limited resources in the community, but it was also due to the stigma surrounding the need for assistance in these types of situations. This tragedy had a profound impact on the views of access to mental healthcare for first responders the community.
Qualitative data demonstrates that fire and EMS responders experience barriers to mental healthcare within the scope of their employment as a first responder, especially in rural communities. Rural first responder agencies recognize the sensitive nature of the project topic. Research demonstrates that departments have implemented efforts to reduce the stigma facing mental healthcare access for department personnel. However, due diligence and education do not seem to be having the impact on the stigma the department has been hoping for. Rural communities recognize the limited access to mental health services available. While there is increased attention to mental healthcare in the community, it does not seem to be impacting first responder perceptions.
The Rural Health Information Hub estimates that $193.2 billion dollars is lost every year in the U.S. due to mental health conditions.7 Mellow believes there are significant hurdles facing the public safety community with respect to access to quality mental healthcare, which contributes to high suicide rates, sick days and lost wages.5 There needs to be a greater focus on the nature and scope of the problem surrounding mental healthcare access in rural communities. The Substance Abuse and Mental Health Services Administration believe that first responders develop mental health conditions at a rate disproportionate to the general population. This is attributed to the experience of more challenging, dangerous, and strenuous situations first responders face.10
Research by the CDC also indicates that first responders are at 10 times the risk for suicidal thoughts or attempts than the general public (Bradley University, n.d.). It is also important to note that while first responders may not experience symptoms of severe mental illness, their stress may manifest in other ways. These can include sleep disorders, temperament disorders, and substance abuse disorders. Research demonstrates the many barriers to mental healthcare in the United States, and these barriers may be more significant for first responders.
Current Situation
According to Mental Health First Aid (2019) statistics, approximately 85% of first responders experience symptoms related to mental health issues, with 75% of these first responders reporting symptoms associated with trauma experienced on the job.6 Brown believes that access to mental healthcare is partially blocked due to a long-standing stigma surround mental health and first responders,2 which is correlated by a national survey that revealed 40% of first responders believed there would be some sort of negative response from their employers for seeking help with their mental health issues.6 Fear, ridicule, prejudice, discrimination and labeling are all associated with this reported stigma, with many responders noting that they have bias towards mental health populations themselves.2
Barriers to access and treatment also prevent first responders from seeking care. Brown also contends that there needs to be a greater focus in identifying and removing barriers to care to help ensure that our first responders have access to the care they need to address their mental health challenges. Access to care correlates to limited community resources, delayed appointment leading to delayed treatment or limited resources sponsored through employment services. Access could also include the limitations in health literacy, correlating to first responders not knowing where to go to receive help or how to ask for help in the first place.
Rural Healthcare Challenges
The Rural Health Information Hub (2018) highlights a growing and significant need for mental health services in rural America.9 A 2017 survey reported that almost 20% of rural residents face issues with their mental health, while approximately 5% of rural residents report serious thoughts of suicide. While nearly one-in-five U.S. adults face mental health disorders, cultural misconceptions and stigma prevent patients from seeking treatment in rural communities.9
Rural Americans currently experience increased difficulty in accessing healthcare across the board when compared to their urban counterparts.8 This reduced access to care contributes to disparities in healthcare outcomes, especially for patients suffering from mental health issues. Specialty providers are often limited in rural communities, especially for mental health, leaving primary care providers and general practitioners to fill in the gaps.8 According to the group, 53.27% of the mental health professional shortage occurs in rural areas. This translates to 90 million Americans having limited access to a mental health professional.7 Telehealth providers are being used to fill in the gaps in mental healthcare access in rural communities. These services have been found to be effective in bridging access to care gaps and are gaining acceptance in rural communities. However, access to these services is largely dependent on fragile rural healthcare networks where 83 rural hospitals closed between January 2010 and January 2018.4
Even though first responder mental health has been a national discussion in recent years, efforts to improve understanding and perception of mental health challenges have only recently gained extra media attention, increasing awareness. Yet, barriers perceived by rural first responders with regard to mental health services in rural communities demonstrates the need for improved access and awareness, as awareness of community mental health resources is cited as the number one barrier to access to care. Rural Fire and EMS providers overwhelming acknowledge the increased risk their profession in a rural community places them at for mental health challenges. While the limited availability, awareness, and resources of mental healthcare in rural communities has been nationally acknowledged, limited resources continues to be an issue.
Conclusion
It is well recognized that first responders experience mental health challenges at a far greater rate than the general population. It is also well established that there are barriers to care in rural communities across the country. Tragedy changes a community. The lasting effects can change the nature of our first responders. Qualitative data supports the need for corrective action in small towns to ensure that another first responder does not become another national statistic.
References
1. Agrawal N. (2019, Mar 1). Firefighter suicides reflect toll of longer fire seasons and increased stress. Los Angeles Times. Retrieved from https://www.latimes.com/local/lanow/la-me-ln-firefighter-suicides-20190302-story.html?fbclid=IwAR3Kf9dpFDu0RgtHU3MP3P8vxCjKZEhqRRRrue6kda-8KvNBj4x_-CQ-NAg.
2. 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.
3. Hicks J. (2019, Mar 5). Truckee Meadows Fire Protection District develops peer support program for fire fighters. MyNews4. Retrieved from https://mynews4.com/news/local/truckee-meadows-fire-protection-district-develops-peer-support-program-for-firefighters?fbclid=IwAR0Hz9dkuIe2lLFOE9JMkCcypphKGTZN_k-gGqposaGoGcJ4KBtzyVXRO8I.
4. Lovelace B. & Schoen J. (2018, Mar 24). Here’s a map of where rural hospital closures are happening in the U.S. CNBC. Retrieved from https://www.cnbc.com/2018/03/23/heres-a-map-of-where-rural-hospital-closures-are-happening-in-the-us.html.
5. Mellow R. (2017). Groundbreaking data collected on mental health of first responders. Journal of Emergency Medical Services, 42(11). Retrieved from https://www.jems.com/articles/print/volume-42/issue-11/departments/evidence-based-ems/groundbreaking-data-collected-on-mental-health-of-first-responders.html.
6. Mental Health First Aid. (2019). Mental health first aid — Fire & EMS. Retrieved from https://www.mentalhealthfirstaid.org/population-focused-modules/fire-and-ems/.
7. Rural Health Information Hub. (2019). Defining mental health in rural communities. Retrieved from https://www.ruralhealthinfo.org/toolkits/mental-health/1/definition.
8. Rural Health Information Hub. (2019). Healthcare access in rural communities. Retrieved from https://www.ruralhealthinfo.org/topics/healthcare-access.
9. Rural Health Information Hub. (2018). Rural mental health. Retrieved from https://www.ruralhealthinfo.org/topics/mental-health.
10. Substance Abuse and Mental Health Services Administration. (2018). First responders: Behavioral health concerns, emergency response, and trauma. Retrieved from https://www.samhsa.gov/sites/default/files/dtac/supplementalresearchbulletin-firstresponders-may2018.pdf.
