“When I signed up for this, no one told me, ‘Hey, when you are involved with this work you have a lifetime higher rate of suicide,’” said Dr. Drew Anderson, while speaking on the mental risks endemic to being a prehospital-care provider.
His presentation is available online through the New York State NYCARESUP program. It covers the recognized problem of increased suicide risk, as well as the following:
- Increased rates of depression.
- Substance abuse and PTSD among first responders.
- How EMS, first responders, corrections officers, and military veterans can address and reduce these problems.
Drew Anderson is a practicing psychotherapist, specifically a clinical psychologist, with 30 years of experience. He has been a university professor of psychology for over 25 years, and he has 12 years of service as a first responder in both EMS and volunteer firefighting. Over the years these activities have often merged, as evidenced by his presentation, Mental Health & Well-Being in Emergency Services & Corrections.
The presentation featured on the website NYCARESUP.com. This website is run as part of the NYCARESUP program created by the Suicide Prevention Center of New York, part of the New York State Office of Mental Health.
In one word, Anderson described the difference between the goals of the program and the way most prehospital care providers approach rescue and hazardous situations. “Awareness,” he said. “We’re trying to train people to the awareness level. We want them to recognize a problem when they see it and address it or refer it appropriately.”
As with technical rescue situations or hazardous materials incidents, the goal is not to transform all EMS people into experts, but instead to develop awareness and knowledge in how best to utilize existing resources and call upon genuine experts as needed with the goal being to reduce suffering, tragedy, and loss of life.
Anderson’s presentation can be split into two distinct parts. The first half is about the risks and emotional and mental health hazards endemic to EMS and similar fields. The second half is about what responders and other uniformed personnel can do to reduce their personal risk. This article focuses on the first half. A later article will cover the second half.
Hazards
Anderson targeted four specific hazards:
- Suicide.
- Post-traumatic stress disorder (PTSD).
- Substance abuse.
- Depression.
Here’s a close-up look at how he addressed each one.
Suicide
A large part of the program focused on increased suicide risk among EMS and other uniformed personnel. According to Anderson, the suicide rate among emergency medical services and other first responders outstrips line-of-duty deaths. This increased risk of suicide is life long and does not go down when one leaves the field or retires. Therefore, the problem is rooted in something more complex than simple exposure to bad things.
To explain this Anderson calls upon something called “Thomas Joiner’s Interpersonal Theory of Suicide.” (When Anderson speaks, he often adds an aside or two about “sounding like a university professor” or says, “This brings out the university professor in me.” And although he does sound a bit embarrassed by it, he does so in a good way.) Regardless, understanding Joiner’s theory helps EMS providers with self-care and care of patients.
The essence of the theory is that for a suicide to occur, two factors must be present in a potentially suicidal person.
- The person must have a desire to be dead. The person must want to kill themselves, end their life, and be dead. “Suicide is an escape from pain,” said Anderson.
- The person must also have the capability of killing someone and performing a violent act against themselves. Many people are psychologically incapable of performing violent acts against themselves or others. (Not that that is a bad thing, mind you.) Exposure to pain, suffering, and death—all obvious parts of being a first responder—increase a person’s ability to perform violent acts against others or themselves and therefore increase one’s ability to take their own life.
“The idea is that suicide is a relief from pain,” he said, speaking in general terms. But then he focuses directly on what triggers EMS providers and other first responders to take their own lives. “We spend a lot of time focusing on bad calls,” Anderson said. “We activate critical incident teams and things like that, and I’m not saying that’s wrong, but what we find is that if we actually ask people who made a suicidal attempt and survive and we interview them, it is not critical incidents that are what causes this to happen…those critical incidents have set the stage.
They have increased your capacity [for suicide] over the years, Then, what you have is normal life stuff. Going through a divorce, financial difficulties, other life stressors that would make a person upset…but the capacity [for committing suicide] is there. That’s what triggers that crisis, which can last for a relatively short period of time. … It’s the normal everyday stresses of life that do it to us, we just happen to have set ourselves up by what we do to be more vulnerable, at a higher risk of that, for suicide.”
A major goal of the program is to increase awareness of signs and causes of suicide, combine this with an awareness of resources to reduce the risk or prevent suicide, and thereby reduce the rate of suicides among first responders.
PTSD
Among the general public, there is probably no psychological disorder linked as closely to emergency services work as PTSD, or, as it is more properly known, post-traumatic stress disorder.
And there’s some truth to this. According to Anderson, 20% to 33% of first responders show signs and symptoms of PTSD. This is a rate that is three to four times higher than the rate for the general public. While the obvious explanation is simply that emergency responders are exposed to stressful, disturbing incidents at a much higher rate than the general public, another is that unlike the general public, emergency responders often don’t get time to recover between incidents.
“It’s the equivalent of running on a broken leg,” he said, explaining that EMS and other emergency responders or uniformed personnel are required to respond to traumatic events when they have not yet processed or recovered from a previous traumatic event.
Again, Anderson does not obsess over diagnostic details. Why should he if the audience is made up primarily of first responders, a group already familiar with the condition? He quickly displays a slide explaining that for a PTSD diagnosis, a person must experience or witness a traumatic event, then show symptoms such as intrusive thoughts, avoidance, mood and cognitive changes, and arousal symptoms.
And PTSD has many layers. “PTSD is associated with depression, alcohol abuse, lower quality of life, and suicidality,” according to Anderson’s presentation.
He emphasized that after extreme experiences, it is not abnormal for someone to show the signs, symptoms, and behaviors associated with PTSD. So people must remember that after a particularly harsh event, if one shows the signs and symptoms of PTSD, they should not be diagnosed with the condition unless these signs and symptoms persist.
PTSD is known for including experiences that involve risk to self or seeing bad things happen or that have happened to others, Anderson spoke of a related and newly recognized issue: “moral injury.” “It’s kind of new. It’s something we associate with PTSD. But it’s a little bit different,” he said.
He defines moral injury as a sense of outrage and upset over a situation that simply does not seem fair or morally correct. Often this involves someone who witnessed an event or didn’t stop something that they felt was morally or ethically wrong.
He said the problem and effects of “moral injury” were first recognized during the Gulf War, but an example closer to EMS was outrage over shortages of personal protective equipment especially during the pandemic. This led to feelings of anger, guilt, and regret, which grew to produce symptoms like those of PTSD, as well as a greater risk for the same problems associated with PTSD.
“We treat it like PTSD,” he said. “It’s a rising issue. We may have missed the boat. Maybe not exactly PTSD, but something similar.”
“It [PTSD] tends to be chronic without treatment,” Anderson said. But he emphasized that there are treatments for it. [These will be covered in part two of this article.]
Substance Abuse
As with the other topics, Anderson did not obsess over diagnostic minutia when he addressed the issue of substance abuse among first responders. He defined it as “a level of substance abuse that interferes with family relationships, missing work, interfering with other areas of one’s life.”
EMS providers have a rate of substance abuse that is two to four times higher than that of the general public. Anderson noted that almost all the data on the subject tends to focus on alcohol, with very little real information available on the abuse of other substances, including marijuana, among EMS providers.
Two main reasons for higher-than-average rates of alcohol abuse among first responders, he said, were as follows:
- Its use as a coping mechanism for dealing with upsetting situations, which EMS providers see and deal with at a much higher rate than the general public.
- The traditional acceptance of alcohol use in many cultures including American culture.
Depression
“When people say the word depression, they mostly think, Well, that person is sad all the time,” Anderson said. And low mood is one of depression’s main symptoms. But we also see a lot of irritability.
And one of the symptoms that often flies under the radar is a loss of interest in pleasure. It’s called “anhedonia,” which means “loss of interest in pleasure” in Latin. It’s basically people saying, ‘I just don’t want to do it anymore’ [referring to fun activities and hobbies]. That is a symptom of depression.”
Other symptoms he mentioned included:
- Changes in sleep (sleeping more or less than usual).
- Changes in appetite.
- Feelings of worthlessness or guilt.
- Higher levels of suicidality.
According to Anderson, the depression rate among emergency medical responders is 7% to 12%. This is significantly higher than the estimated 5% rate among the general public, according to the Centers for Disease Control and Prevention.
According to Anderson, the subset of people most prone to depression are people who react to stress by withdrawing. While he said the rates of depression among EMS providers are nowhere near the general public as some of the other issues he discusses, as the condition is associated with a lower quality of life when compared to some other issues.
References
“Depression.” National Center for Health Statistics, Centers for Disease Control and Prevention, 2024, cdc.gov/nchs/fastats/depression.htm.
“Mental Health & Well-Being in Emergency Services & Corrections.” New York State Office of Mental Health, September 2022, bit.ly/3BO3wsU.
QOL Consulting LLC, 2024, qolconsultingllc.com/drew-anderson.php.
Chu, C., Buchman-Schmitt, J. M., Stanley, I. H., Hom, M. A., Tucker, R. P., Hagan, C. R., Rogers, M. L., Podlogar, M. C., Chiurliza, B., Ringer, F. B., Michaels, M. S., Patros, C. H. G., & Joiner, T. E. (2017). The interpersonal theory of suicide: A systematic review and meta-analysis of a decade of cross-national research. Psychological bulletin, 143(12), 1313–1345. https://doi.org/10.1037/bul0000123
