Practitioner Mental Wellbeing: Can We Be More Proactive?

As many within our profession begin to address the issue of practitioner mental health, we as paramedicine leaders should become more engaged in the topic. Part of our responsibility as managers of EMS organizations is to provide as safe a workplace as possible, and to help our providers maintain good mental health and overall wellbeing. It’s not only the right thing to do; caring for our colleagues, is cost effective and reduces long-term expenses that result from lost work days and medical costs.

Attention to this subject has intensified and become more focused since JEMS Editor-in-Chief A.J. Heightman declared a call to action (which he named the Alliance on EMS Resiliency) at the 2016 EMS Today Conference. He recognized the work the NEMSMA Practitioner Wellbeing Committee had done regarding provider suicide, and the landmark white paper they published that year.

NEMSMA has been proud to act as the facilitator for the nation’s various industry associations, who are working together to address the topic, through the Alliance.

One area that’s fundamentally necessary to explore in order to understand this issue–and one in which we lack adequate awareness–is research into the causes and exacerbating factors of debilitating mental stress our practitioners endure. Substantial work has been done in other countries, but we need to examine the nuances associated with our unique American culture, and that of our profession as it exists within the U.S.

A substantial number of studies in this area have been done over the years, but not specifically regarding the paramedicine industry. They’ve been targeted more toward the general public in various workplace settings, police officers, firefighters and combat veterans. This body of research is a good place to start and as we design more focused studies specifically examining our industry.

So, what do we know thus far about the causes of mental illness and what affects its various elements?

Chronic Pain

Research has revealed that chronic pain is strongly associated with increased incidences of suicide and suicidal ideation.1,2 Other research has drawn the conclusion that multiple sources of chronic pain compound the potential for suicide and violent impulses. They also reveal that the degree to which chronic pain interferes with an individual’s ability to engage in social, recreational, emotional and physical activities, is a stronger indicator of suicidal and violent ideation than the intensity of the pain itself.3

Additionally, some research indicates that a person’s perception of the severity of the pain from which they suffer, and their tolerance of it, is influenced adversely when also suffering from a mood spectrum disorder (MSD).4

So, physical injuries suffered by our practitioners, as well as their emotional state of mind, substantially influence their predisposition to thoughts of suicide and violence. Whether their injuries or mental stress are work-related or not, they have an impact on their wellbeing and susceptibility to suicide ideation and violent behavior. Furthermore, their susceptibility to taking deleterious actions worsens when they have additional mental illnesses.

Perhaps expanding our risk management processes to now include a focus on these areas would help us identify employees at risk and provide us the opportunity to intervene in advance of a provider developing symptomatology of suicide or self-destructive behavior.  

Psychological Pain

Feelings of mental distress from a non-physical source or sources, emotional suffering and mental torment are all definitions of psychological pain. This term is becoming increasingly accepted within the medical community.5

Research demonstrates that elevated levels or intensity of psychological pain are strongly associated with increased suicidal ideation and self-injurious acts.6—8

Other research indicates that the higher the tolerance an individual has for psychological pain and their self-perceived ability to cope with that pain, the less likely they are to attempt suicide.9

Therefore, it’s not just physical pain that can aggravate a practitioner’s mental distress and increase their likelihood of suicide, violent behavior and self-harm; it’s also psychological pain. It doesn’t matter whether their physical or psychological pain is work-related.

Therefore, the concept of teaching mental resiliency and coping skills to practitioners that might mitigate or interrupt the path toward suicide and self-harm, seems quite feasible.


Research has also shown a link between post-traumatic stress disorder (PTSD) and chronic pain severity. Persons who suffer from PTSD are likely to perceive their pain as more intense or severe. When successfully treated for PTSD, their sense of pain reduces as well.10 Other studies have concluded that a prevalence of PTSD exists with individuals suffering from clinically diagnosed chronic pain.11

Thus, we know that a practitioner suffering from PTSD and/or an MSD is likely to perceive any physical pain they’re experiencing with more intensity. We also know that the more severe and chronic the physical pain suffered by a person, the more likely they are to think about suicide and exhibit violent behavior. Therefore, chronic pain in the presence of PTSD and/or an MSD substantially exacerbates the risk to our practitioners for debilitating mental illness that leads to suicide and self-injury.

Again, establishing mechanisms to identify staff who suffer from PTSD and/or MSDs, along with chronic physical and/or psychological pain, would allow paramedicine leaders to provide timely interventions designed to mitigate their predisposition for suicide and suicidal ideation, as well as self-injurious or violent behavior.


1. Legarreta M, Bueler E, DiMuzio J, et al. Suicide behavior and chronic pain: An exploration of pain-related catastrophic thinking, disability, and descriptions of the pain experience. J Nerv Ment Dis. 2018;206(3):217—222.

2. Racine M. Chronic pain and suicide risk: A comprehensive review. Prog Neuropsychopharmacol Biol Psychiatry.  Aug. 26, 2017. [Epub ahead of print.]

3. Blakey S, Wagner H, Naylor J, et al. Chronic pain, TBI, and PTSD in military veterans: A link to suicidal ideation and violent impulses? J Pain. 2018;19(7):797—806.

4. Ciaramella A. Mood spectrum disorders and perception of pain. Psychiatr Q. 2017;88(4):687—700.

5. Biro D. Is there such a thing as psychological pain? And why it matters. Cult Med Psychiatry. 2010;34(4):658—667.

6. Ducasse D, Holden R, Boyer L, et al. Psychological pain in suicidality: a meta-analysis. J Clin Psychiatry. 2018;79(3). pii: 16r10732.

7. Rizvi S, Iskric A, Calati R, et al. Psychological and physical pain as predictors of suicide risk: Evidence from clinical and neuroimaging findings. Curr Opin Psychiatry. 2017;39(2):159—167.

8. Conejero I, Olié E, Calati R, et al. Psychological pain, depression, and suicide: Recent evidences and future directions. Curr Psychiatry Rep. 2018;20(5):33.

9. Meerwijk E, Weiss S. Tolerance for psychological pain and capability for suicide: contributions to suicidal ideation and behavior. Psychiatry Res. 2018;262:203—208.

10. Siqveland J, Hussain A, Lindstrà¸m J, et al. Prevalence of posttraumatic stress disorder in persons with chronic pain: A meta-analysis. Front Psychiatry. 2017;8:164.

11. Siqveland J, Ruud T, Hauff E. Post-traumatic stress disorder moderates the relationship between trauma exposure and chronic pain. Eur J Psychotraumatol. 2017;8(1):1375337.

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