Recent natural and human-made disasters have focused public attention on the health care needs of protective services workers (PSWs). Numerous studies have examined adverse physical health effects of exposure to smoke and harmful chemicals during emergencies.1-Reference Wheeler, McKelvey and Thorpe7 However, the mental health care needs of PSWs have received less attention. It is now well-established that exposure to traumatic events can lead to emotional difficultiesReference Papageorgiou, Frangou-Garunovic, Iordanidou, Yule, Smith and Vostanis8 and problematic substance use,Reference Lacoursiere, Godfrey and Ruby9 and PSWs, many of whom are exposed to potentially traumatic events as part of their jobs, may be at greater risk for these outcomes.Reference North, Tivis and McMillen10-Reference Perrin, DiGrande, Wheeler, Thorpe, Farfel and Brackbill13 For example, North and colleagues found a high prevalence of alcohol abuse and dependence among PSWs exposed to the Oklahoma City bombing.Reference North, Tivis and McMillen10 Similarly, studies of PSWs involved in the rescue operations following the 9/11 terrorist attacks have reported high prevalence of mental health problems affecting these workers’ functioning.Reference Perrin, DiGrande, Wheeler, Thorpe, Farfel and Brackbill13, Reference Stellman, Smith and Katz14 In addition, in the aftermath of Hurricane Katrina, a study showed that approximately one-fifth of police officers and firefighters experienced symptoms of posttraumatic stress disorder, and more than a quarter reported symptoms of depression.15 Although these findings in PSWs involved in highly publicized mass traumas provide important information, we know little about the prevalence of mental health problems and the impact of exposure to traumatic events on the mental health of the general population of PSWs.
In this study, we compared the prevalence of psychiatric disorders in a nationally representative sample of PSWs with the prevalence of these disorders in workers in other occupations. We also examined the association of exposure to common traumas with the development of mood, anxiety, and alcohol disorders among PSWs who recently joined the workforce and those who had been in these jobs for a longer period. Based on past research,Reference North, Tivis and McMillen10, Reference North, Tivis and McMillen11, Reference Perrin, DiGrande, Wheeler, Thorpe, Farfel and Brackbill13, Reference Stellman, Smith and Katz14, Reference Fullerton, McCarroll, Ursano and Wright16, Reference Fullerton, Ursano and Wang17 we hypothesized that PSWs would have a higher prevalence of mental and substance-use disorders. We also hypothesized that they would be more likely to be exposed to potentially traumatic events than adults in other occupations, and that there would be an association between exposure to these events and the risk of incident mental disorders in these workers.
Methods
Sample
The sample for this study was drawn from waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). NESARC is a representative survey of the US general population, including residents of Hawaii and Alaska, conducted by the National Institute on Alcohol Abuse and Alcoholism. The NESARC sample was weighted to adjust for the unequal probabilities of selection and to provide nationally representative estimates. The data were collected at 2 time points: wave 1 of the survey was conducted between 2001 and 2002, and wave 2 was conducted between 2004 and 2005.
NESARC wave 1 included 43 093 participants who were 18 years and older. Of these, 39 959 persons were eligible for wave 2 interviews. Ineligible respondents were those who could not participate in the survey because of mental or physical impairment, or were on active duty in the military. Respondents were also ineligible at follow-up if they were deceased or deported. A total of 34 653 of eligible wave 1 participants were successfully followed up and interviewed in the wave 2 survey. The response rates for wave 1 and eligible wave 2 surveys were 81% and 87%, respectively.
Participants identified their current occupation from a list provided by study interviewers. The job status of participants of the 2 survey waves and movement into and out of the different occupation groups are presented in the Figure. NESARC defined protective services jobs as firefighters, police officers, and crossing guards. We based the analyses for the comparison of mental disorder prevalence between PSWs and other occupations on the wave 1 sample. A total of 26 979 NESARC wave 1 participants were employed at the time of interview—474 were employed in protective services and 26 505 were employed in other occupations. Analyses of incident exposure to potentially traumatic events were based on 479 PSWs and 21 423 participants in other occupations at wave 2. Finally, to assess the association of exposures with incident disorders, we focused on the 479 PSWs in wave 2.
Assessment of Mental and Substance-Use Disorders
To derive diagnoses of the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) Axis I and Axis II (personality) disorders, NESARC used the Alcohol Use Disorder and Associated Disabilities Interview Schedule, DSM-IV version (AUDADIS-IV), a structured diagnostic interview designed for use by lay interviewers to detect the presence of mental disorders in the general population.Reference Hasin, Carpenter, McCloud, Smith and Grant18-Reference Ruan, Goldstein and Chou21 To receive a DSM-IV Axis I diagnosis, respondents needed to endorse the DSM-IV symptom criteria for that disorder along with distress or social/occupational dysfunction. The AUDADIS-IV measured the lifetime and recent (past 12 months) presence of mood, anxiety, and substance-use disorders, as well as lifetime diagnoses of several DSM-IV Axis II personality disorders. To minimize participant burden, some personality disorders were assessed in wave 1 and others in wave 2. In this study, we included only personality disorders in wave 1 (which included antisocial, avoidant, dependent, obsessive compulsive, paranoid, schizoid, and histrionic personality disorders), because responses in wave 2 might have been influenced by incident Axis I disorders. The reliability and validity of AUDADIS-IV have been previously established.Reference Hasin, Carpenter, McCloud, Smith and Grant18-Reference Grant, Stinson, Dawson, Chou and Ruan25
We studied lifetime and past 12-month diagnoses of mood disorders (including depressive episode, manic episode, hypo-manic episode, and dysthymia), anxiety disorders (including panic disorder, social phobia, specific phobia, and generalized anxiety disorder [GAD]), and alcohol abuse or dependence that were measured at wave 1. We excluded non-alcohol drug-use disorders from this study, owing to the small number of participants with these disorders in the PSW sample. For example, only 5 of the 479 PSWs reported nonmedical use of narcotics. We also studied incident mood, anxiety, and alcohol disorders at wave 2. Participants were rated as having an incident disorder if they did not meet the criteria for that disorder at wave 1, but did meet the criteria at wave 2.
Posttraumatic stress disorder (PTSD) was only assessed at NESARC wave 2. We therefore separately compared the lifetime prevalence and new-onset PTSD (onset after wave 1 interview based on self-report of timing of onset at wave 2) between the PSWs and participants in other jobs.
Assessment of Exposure to Potentially Traumatic Events
NESARC also queried respondents at wave 2 about whether they had experienced a number of life events, and the age at which the respondent experienced these events for the first time and most recently. In this study, we examined the following events that were most relevant to PSWs: (1) having experienced a serious/life threatening accident; (2) having been in a serious fire, tornado, flood, earthquake, or hurricane; (3) having been physically attacked/beaten/injured; (4) having been kidnapped or held hostage or as a prisoner of war; (5) having been mugged, held up, or threatened with a weapon; and (6) other than a terrorist attack, having seen someone badly injured/killed or unexpectedly having seen a dead body. Because terrorism-related events were infrequently reported, we generated a composite variable by merging the following terrorism related variables into a single dichotomous variable: directly experiencing a terrorist attack by the participant or someone the participant knows, injury to the participant or someone close to the participant in a terrorist attack, and death of someone close to the participant in a terrorist attack. Respondents who endorsed any of these terrorism-related events were given a positive rating on the terrorism-related exposure variable.
For each event, we studied both lifetime exposure, as measured at wave 2, and recent exposure (occurring between wave 1 and wave 2). Because life events were not assessed during wave 1, we defined recent exposures as events that a participant reported having experienced at an older age than that participant's age at wave 1. For example, if a participant reported in the wave 2 interview experiencing an event for the last time at age 22, and that participant was 21 years old at wave 1, the participant was rated as having experienced the exposure between waves 1 and 2, and that exposure was considered recent.
To assess the impact of exposure to multiple events, we developed a trauma index by summing the number of different types of recent potentially traumatic events. Because very few participants reported more than 3 types of recent events, we combined 3 or more exposures into a 3+ category. Thus, the trauma index values ranged from 0 (ie, no recent exposures) to 3+ (ie, 3 or more types of recent exposures).
Statistical Analyses
We conducted 3 sets of analyses. First, binary logistic regression analyses were used to compare the prevalence of mood, anxiety, alcohol, and personality disorders between the participants who were in protective services and participants in other occupations at wave 1. Mental disorders were the dependent variables, and occupation (PSWs = 1, other occupations = 0) was the independent variable of interest. To determine if the prevalence of disorders differed in workers who left the protective services profession between waves 1 and 2, we repeated these analyses comparing 161 PSWs who left protective services by wave 2 to 197 workers who had remained in protective service jobs. These analyses controlled for age, sex, minority status, education, income, and marital status—socio demographic characteristics that were significantly different between PSWs and other workers at P < .20.
Next, we compared the prevalence of lifetime and recent potentially traumatic exposures between PSWs and individuals in other occupations in multivariable binary logistic regression models, controlling for the same variables as in the prior analyses. To determine whether workers who joined the protective services between waves 1 and 2 (early career PSWs) had a different trauma exposure profile than those who were in these occupations at both waves, we repeated these analyses comparing 282 early career PSWs and the 197 workers who were PSWs at both waves.
Finally, to assess the relationship between potentially traumatic exposures and development of adverse mental health outcomes among PSWs at wave 2, we used binary logistic regression models to examine the association of the trauma index (0, 1, 2, or 3+ exposure types, treated as a continuous variable) and incident (ie, with onset between waves 1 and 2) mood, anxiety, and alcohol-use disorders. Because traumatic exposures may have affected workers depending on when they joined these occupations, we also conducted these analyses separately in early career PSWs and workers in protective services at both waves. Because personality disorders may impact vulnerability to future mood, anxiety, and substance disorders, these analyses were adjusted for wave 1 personality disorders in addition to the other control variables described earlier.
Prevalence of mental disorders in an occupational group may be affected by selective exit from the workforce by individuals with mental health problems. To assess this possibility, in a set of further analyses, we examined the association of mental disorders at baseline or incident mental disorders during the follow-up with leaving protective services jobs.
Results
Sample Characteristics
At wave 1, there were 474 NESARC participants in protective services occupations and 26 505 in other occupations. PSWs were more likely than participants in other occupations to be male (72% vs 48%, OR = 2.83, 95% CI = 2.31-3.47, P < .001) and of minority status (58% vs 44%, OR = 1.74, 95%CI = 1.45-2.09, P < .001). The occupation groups did not differ by age, education level, income, or marital status.
Prevalence of Mental Disorders
Alcohol abuse and dependence (37%) and depressive episodes (15%) were the most common lifetime mental health problems among PSWs at wave 1 (Table 1). Alcohol abuse and dependence (10%) and depressive episodes (5%) were also the most common disorders within the past 12 months in this group. After adjusting for socio demographic characteristics, PSWs did not differ significantly from other workers with regard to the lifetime and 12-month prevalence of most mood, anxiety, and alcohol-use disorders. However, PSWs had a lower prevalence of lifetime GAD and social phobia, and a lower 12-month prevalence of GAD, as compared to participants in other occupations.
Table 1 Lifetime and 12-Month Prevalence of Mood, Anxiety, Alcohol, and Personality Disorders Among Protective Services Workers (PSWs) and Workers in Other Jobs in the National Epidemiologic Survey on Alcohol and Related Conditions, Wave 1
aPercentages calculated using wave 1 survey weights to provide nationally representative estimates of US population.
bOdds ratios calculated using wave 1 survey weights and adjusted for age, sex, minority status, education, and income.
cWith or without agoraphobia.
dIncluding conduct disorder.
In further analyses, the lifetime and 12-month prevalence of the cited mood, anxiety, and alcohol-use disorders at wave 2 did not differ between PSWs and other occupation groups (data not shown). We also compared the lifetime and 12-month prevalence of PTSD at wave 2. Participants who were PSWs at wave 1 did not differ from those in other jobs with regard to either the lifetime or 12-month prevalence of PTSD at wave 2 (data not shown).
Potentially Traumatic Exposures
The sample for the analyses of traumatic exposures was limited to wave 2 participants who reported being PSWs (N = 479) and other occupations (N = 21 423) (Figure). Among PSWs, the most commonly reported lifetime and recent exposures were seeing someone badly injured/killed or unexpectedly seeing a dead body (lifetime = 52%, recent =30%), having someone close die unexpectedly (lifetime = 45%, recent = 16%), and having someone close experience a serious/life-threatening illness, accident, or injury (lifetime = 45%, recent = 18%) (Table 2).
Figure Job Stability and Change in Workers in Protective Services and Other Jobs Between Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions.
Table 2 Lifetime and Recent Exposure to Potentially Traumatic Events Among Protective Services Workers (PSWs) and Participants in Other Jobs in National Epidemiologic Survey on Alcohol and Related Conditions, Wave 2
aPercentages calculated using wave 2 survey weights to provide nationally representative estimates of US population.
bOdds ratios used wave 2 survey weights and adjusted for age, sex, minority status, education, income, and marital status at wave 1.
PSWs were more likely than participants in other occupations to report potentially traumatic events (Table 2). After controlling for socio demographic characteristics, PSWs were more likely than other workers to report a lifetime history of having seen someone badly injured/killed, or to have unexpectedly seen a dead body (AOR = 2.80, 95% CI = 2.25-3.50, P < .001); having been physically attacked, beaten, or injured (AOR = 2.03, 95%CI = 1.49-2.78, P < .001); and having been mugged, held up, or threatened with a weapon (AOR = 1.84, 95% CI = 1.38-2.46, P < .001). Further-more, between waves 1 and 2, PSWs had greater odds of having been mugged, held up, or threatened with a weapon (AOR = 7.37, 95% CI = 4.23-12.83, P < .001); having been physically attacked, beaten, or injured (AOR = 7.20, 95% CI = 3.33-15.57, P < .001); and having seen someone badly injured or killed (AOR = 7.03, 95% CI = 5.56-8.88, P < .001).
To determine if the experiences of PSWs differed depending on when they joined the protective services workforce, we compared the experience of traumatic exposures in early career PSWs at wave 2 and participants who were in protective services jobs in both waves. Early career PSWs were more likely than those in protective services jobs at both waves to have never been married (31% vs 20%, OR = 2.02, 95% CI = 1.29-3.17, P = .002). In addition, early career PSWs were less likely than those in protective services jobs at both waves to be male (65% vs 80%, OR = 0.48, 95% CI = 0.31-0.73, P = .001), to have more education than a high school diploma (63% vs 74%, OR = 0.61, 95% CI =0.41-0.91, P = .016), and to have an annual income greater than $20 000 (83% vs 90%, OR = 0.52, 95% CI = 0.30-0.92, P = .024). Compared to those who were PSWs at both waves, early career PSWs also had lower odds of having seen someone injured during their lifetime (43% vs 66%, AOR =0.46, 95% CI = 0.26-0.81, P = .010) and since wave 1 (21% vs 43%, AOR = 0.48, 95% CI = 0.27-0.83, P = .012). These groups did not differ with respect to any other exposure types assessed.
Recent Exposure to Potentially Traumatic Events and Incident Mental Disorders
Analyses for the association of recent traumatic exposure (between waves 1 and 2) and incident mental disorders focused on participants who were PSWs at wave 2. For each additional traumatic event type experienced, PSWs had 1.87 (95% CI = 1.09-3.22, P = .024) times higher odds of developing a mood disorder, and 1.84 (95% CI = 1.16-2.91, P = .011) times higher odds of developing an alcohol-use disorder after controlling for socio demographic characteristics (Table 3). In additional analyses, we focused on the association of exposures with outcomes in early career PSWs. For each additional exposure type, early career PSWs had 2.30 (95% CI = 1.26-4.19, P = .008) times higher odds of developing a mood disorder and 2.44 (95% CI = 1.30-4.58, P = .007) times higher odds of developing an alcohol-use disorder by wave 2 after controlling for socio demographic characteristics (Table 3). Participants who were PSWs at both wave 1 and wave 2 were not significantly more likely to develop mood, anxiety, or alcohol-use disorders by wave 2 with additional traumatic exposure types. We also compared the proportion of PSWs and individuals from other occupations who reported suicidal ideation, and found no significant difference between these groups.
Table 3 The Association of Traumatic Exposure Index ScoresFootnote a With the Development of Mood, Anxiety, and Alcohol Disorders in Protective Services Workers (PSWs) in National Epidemiologic Survey on Alcohol and Related Conditions, Waves 1 and 2
a Higher score corresponds to greater number of exposure types between waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (exposure type range = 0 to 3+).
b Odds ratios calculated using wave 2 survey weights and adjusted for age, sex, minority status, education, income, marital status, and having had any personality disorder at wave 1.
Potentially traumatic exposures were also associated with an increased risk of new-onset PTSD at wave 2 among early-career PSWs, but not among workers who were PSWs at both waves. For each additional traumatic event type experienced, early career PSWs had 6.93 (95% CI = 1.25-38.44, P = .029) times higher odds of developing PTSD between waves 1 and 2 after controlling for socio demographic characteristics. However, these associations were based on a small number of subjects—a total of n = 9 (2%) PSWs at wave 2 reported having developed PTSD since wave 1 (n = 7 [2%] among the early career PSWs and n = 2 [1%] among workers who were in the protective services workforce at both waves).
Mental Disorders Among PSWs Who Left Their Jobs
Of the 474 participants who were PSWs at wave 1206 (43%) were no longer in these jobs by wave 2 (161 changed occupations, 45 became unemployed/retired), and 71 were lost to follow-up (Figure). We conducted additional analyses to determine whether mental disorders at baseline or incident mental disorders during follow-up were associated with leaving protective services jobs. Compared to PSWs who stayed in protective services jobs, those who left were more likely to have never been married (31% vs 20%, OR = 2.07, 95% CI = 1.32-3.25, P = .002). In addition, compared to those who remained in the protective services workforce, those who left were less likely to be male (67% vs 80%, OR = 0.52, 95% CI = 0.34-0.80, P = .003), to have attended college (58% vs 74%, OR = 0.50, 95% CI = 0.33-0.74, P = .001), and to have an annual income greater than $20000 (78% vs 90%, OR = 0.38, 95% CI = 0.22-0.66, P = .001). The prevalence of mental, substance, and personality disorders at wave 1 was similar between PSWs who stayed and those who left these jobs (data not shown).
We also compared the incidence of mood, anxiety, and alcohol-use disorders among PSWs who left these jobs between waves 1 and 2 and those who remained in these jobs in both waves. After controlling for potential confounders, PSWs who left these jobs had higher odds of new-onset anxiety disorders (AOR = 3.75, 95% CI = 1.01-13.91, P = .048) than PSWs who remained in these jobs at wave 2.
Comment
To the best of our knowledge, this is the first study of the prevalence of and risk factors for incident mental disorders in a nationally representative sample of PSWs in the United States. There were 3 main findings in this study. First, after adjusting for socio demographic characteristics, the prevalence of mental health disorders and alcohol abuse and dependence in this nationally representative sample of PSWs was not higher than in other occupations. This finding is at odds with those from previous studies that have shown a higher prevalence of mental and substance disorders in this population.Reference North, Tivis and McMillen10, Reference North, Tivis and McMillen11, Reference Fullerton, Ursano and Wang17 Many of the previous studies, however, were based on samples of PSWs involved in mass traumas,Reference Benedek, Fullerton and Ursano26 such as the 9/11 attack on the World Trade Center and the Oklahoma City bombing, which were of much greater magnitude than the traumas typically faced by PSWs responding to everyday emergencies in communities across the country.
Our second finding was that PSWs experienced a greater number of potentially traumatic events than adults in other occupations. This was not unexpected, as these workers routinely face emergencies that put them at risk for exposure to traumatic events, such as fires and domestic disturbances. The most common of these events—seeing someone who is badly injured, and unexpectedly seeing a dead body—are relatively common in the work of police officers and firefighters.
Our third finding was the association between the number of different traumatic event types and incident mood and alcohol-use disorders, as well as PTSD, which was virtually confined to the group of early career PSWs. Multiple traumatic events were not associated with incident disorders in workers who were in the protective services workforce at both waves. While early career workers generally experienced the same traumatic events as those who were in the protective services workforce at both waves, their relative lack of experience may make them more vulnerable to the development of psychopathology.
It is interesting to note that while PSWs, as a group, were at risk of developing mood and alcohol-use disorders at wave 2 when exposed to a greater variety of potentially traumatic life events, they did not have a higher prevalence of mental disorders than the other occupational groups at wave 1. The discrepancy between the greater incidence and similar prevalence may be explained by the fact that PSWs who left these jobs had a higher incidence of anxiety disorders at wave 2 compared to those remaining in the protective services workforce. Perhaps PSWs who develop a new anxiety disorder are more likely to leave their jobs because the distress and impairment in functioning associated with these mental health conditions make it difficult for them to continue working at their unpredictable and often stressful jobs. However, it is puzzling that the greater incidence of anxiety disorders among the exposed PSWs does not translate into greater prevalence of these disorders in these workers compared to individuals in other occupations. It is possible that exposure-related disorders among PSWs have a shorter durationReference Wakefield, Schmitz, First and Horwitz27; as a result, the prevalence of disorders remains similar among PSWs and other workers. Further studies with larger samples of PSWs and assessment of duration of disorders are needed.
Because of the limited number of PSWs in this study reporting prescription drug abuse, we were unable to explore the misuse of prescription medications within this population. However, the misuse of these substances among PSWs should not be ignored, because the prevalence of opiate and prescription drug abuse in the general population has increased dramatically.28 Prescription drug dependence should be assessed in larger samples of this population.
Our findings suggest that exposure to diverse types of traumatic events among early career PSWs is a risk factor for psychopathology and alcohol-use disorders, and that the development of psychopathology might be associated with attrition from protective services jobs. Efforts to detect, treat, and prevent these outcomes in PSWs are needed, with a focus on individuals who have not yet developed the hardiness and coping skills found in veterans of these jobs. These efforts could be accomplished by ensuring that PSWs have consistent access to mental health screenings,Reference Rutkow, Gable and Links29 which may identify symptoms associated with incident mood and alcohol-use disorders early on. Trainings for PSWs should also emphasize the importance of these screenings and explain how to access them (eg, through an individual's health insurance or through an employer-sponsored assistance program). While mental health screenings should not be compulsory, our results suggest that they should be strongly recommended for early career PSWs, especially those exposed to a wide variety of potentially traumatic events.
Some PSWs, particularly those who are early in their careers, may be reluctant to take advantage of mental health services due to concerns about peers’ and managers’ perceptions of their ability to handle the daily stresses associated with their jobs. To mitigate this, early career PSWs should, as part of job training and orientation activities, receive information about legal protections (ie, Health Insurance Portability and Accountability Act30 and related state-level laws), which require the secure storage of identifiable mental health information and provider confidentiality. These provisions also ensure that such information can only be accessed by health care providers who participate in an individual's care.
Given the potential vulnerability of early career PSWs to certain mental health and substance-use disorders, employers or relevant professional associations may want to establish support programs for these workers. These programs could take the form of confidential counseling services, facilitated group sessions, or the presentation of training curricula that discuss strategies for developing coping skills. Lessons can be learned from efforts to foster resilience among first responders and other work-forces that face routine exposure to traumatic events.Reference Benedek, Fullerton and Ursano26, Reference Everly, Beaton, Pfefferbaum and Parker31 For example, training in psychological first aid, which encourages calmness and connection to social supports while also promoting coping behaviors,Reference Brymer, Jacobs and Layne32 has been shown to enhance individuals’ sense of well-being during an emergency response.Reference Everly, Barnett, Sperry and Links33 In addition, the military has developed a behavioral health force protection model, in which specific risk factors are identified and opportunities for injury prevention are shared directly with individuals most at risk.Reference Stea, Anderson, Bishop and Griffith34 These preventive approaches should, ideally, be provided on an ongoing basis, not merely during an orientation period, to ensure that early career PSWs remain aware of the supportive services available to them as they encounter multiple and varied potentially traumatic events.
Limitations
Our results should be interpreted within the context of the study's limitations. First, assessment of mental disorders was based on self-report, which can be affected by self-stigma and denial. Reluctance of PSWs to admit to mental distress may have led to an underestimation of the incidence and prevalence of these problems. Further, in the general US population, it is estimated that more than half of individuals with psychiatric disorders remain untreated.Reference Wang, Lane, Olfson, Pincus, Wells and Kessler35 Further research is needed to better understand treatment-seeking patterns among PSWs. Second, the NESARC assessed symptoms and life events retrospectively, and respondents with psychiatric disorders might have recalled trauma exposure history differently from those without such disorders. As a result, the association we observed between trauma exposure and incident disorders may have been inflated. Third, the trauma index of recent potentially traumatic events gave equal weight to all events, and did not capture the frequency or magnitude of each specific exposure type. For example, being “physically attacked/beaten/injured” might have had more severe mental health consequences than “seeing a dead body,” and these differences were not reflected in the trauma index. A greater understanding of the impact of specific traumatic events requires studies with larger samples of individuals with trauma exposure and more extensive assessment of different trauma types and mental health outcomes. Fourth, for individuals who joined the protective services workforce between waves 1 and 2, and for those who left these jobs in this interval, we could not assess the temporal sequence of job change and potentially traumatic events. Future research needs to examine the timing of exposures and incident disorders in greater detail. Finally, NESARC did not distinguish between different groups of PSWs (eg, police officers, fire fighters). Future research needs to explore mental health conditions and exposure to trauma in different groups of PSWs separately.
Conclusions
Our findings provide a first glimpse at the prevalence of mental disorders and mental health care needs in a nationally representative sample of PSWs. Our results suggest that PSWs, especially those who are in the early stages of their careers, may be at an increased risk of developing mood or alcohol disorders as a result of their exposure to potentially traumatic experiences. Future research should examine the coping skills of PSWs who have been in these jobs for many years, which might make them less likely to develop psychiatric complications in the face of various potentially traumatic experiences. Instruction in these coping skills could subsequently be incorporated in training curricula for early career PSWs. Special support programs and services for these early career workers can potentially help to prevent development of chronic psychopathology and attrition from these critical jobs.
About the Authors
Department of Mental Health (Drs Spira and Mojtabai and Mr Kaufmann); Department of Health Policy and Management (Dr Rutkow), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
Funding and Support
This research was supported by the Centers for Disease Control and Prevention (CDC) (5P01TP000288-02) through the Johns Hopkins Preparedness and Emergency Response Research Center.
Disclaimer
Any views or opinions expressed in this article are those of the authors and not CDC or other project partners.
Published online: November 27, 2012. doi:10.1001/dmp.2012.55
