Depression

Depression has been commonly reported among first responders, with rates and severity varying across studies. One study of prehospital professionals reported that almost seven percent experienced depression, ^{Reference Bentley, Crawford, Wilkins, Fernandez and Studnek8} while another study found that volunteer firefighters reported markedly elevated levels of depression as compared to career firefighters. ^{Reference Stanley, Boffa, Hom, Kimbrel and Joiner21} The researchers suggested that competing demands for volunteer firefighters, such as having a separate job, can create stress vulnerabilities that contribute to the development or exacerbation of behavioral health conditions.

Organizational factors, such as ineffective screening and training, may also contribute to the differences in mental health impact observed between volunteer and career responders. In another study, 22% of female career and 39% of female volunteer firefighters were at risk of depression. ^{Reference Haddock, Poston, Jahnke and Jitnarin22} A study following police officers after the 9/11 attacks found that almost 25% of them went on to develop depression and nearly 50% experienced both depression and anxiety. ^{Reference Bowler, Kornblith and Li23}

Stress and PTSD

Previously, PTSD has been reported to affect between 15% and 30% of first responders. ^{Reference van Dam, Ehring, Vedel and Emmelkamp24} In a study of prehospital professionals, stress was reported in nearly six percent of personnel. ^{Reference Bentley, Crawford, Wilkins, Fernandez and Studnek8} Paramedics who responded to the same traumatic event reported higher peri-traumatic dissociation compared with responding police. ^{Reference Marmar, McCaslin and Metzler9}

In a study following Hurricane Katrina (2005), PTSD was reported in between seven percent and 19% of a sample of police officers. ^{Reference McCanlies, Mnatsakanova, Andrew, Burchfiel and Violanti25} After the 9/11 attacks, PTSD was reported in 11% of police responders, with PTSD increasing as the level of social support decreased. The prevalence of PTSD prevalence was almost 35% in police officers unable to work because of ill health and almost 51% in those with unmet mental health needs. Prevalence of PTSD was higher in female officers (15.5%) compared to male officers (10.3%). ^{Reference Cone, Li and Kornblith26} In a separate study, the prevalence of probable PTSD in police officers following 9/11 was almost 13%. ^{Reference Bowler, Kornblith and Li23}

A study of US firefighters, while limited due to convenience sampling methods, reported markedly elevated levels of posttraumatic stress in volunteer firefighters while career firefighters reported higher levels of PTSD. ^{Reference Stanley, Boffa, Hom, Kimbrel and Joiner21} It is important to note the link between firefighter PTSD and substance use disorder, with researchers noting that 20% of firefighters have both PTSD and substance use disorders when compared to the general public. ^{Reference Henderson, van Hasselt, LeDuc and Couwels27}

Suicide and Suicidal Ideation

A number of studies have attempted to report the rates of suicide and suicidal ideation among first responders, but there is still a question as to the accuracy of the rates reported given the way data have been collected in samples of convenience versus the use of random samples. Questions have also been raised as to the cohort of personnel included in these statistics. For example, suicides may be recorded for active responders but not retired or veteran staff. Heyman, et al ^{Reference Heyman, Dill and Douglas28} stated that only 40% of firefighter suicides are reported. Despite this limitation, reports have shown that more police officers have died by suicide in recent years in the US compared to those that have died in the line of duty, with 224 police officer suicides compared to 128 officer line-of-duty fatalities. ^{Reference Blue29}

Research also suggests that prehospital personnel may be more likely than the general population to think about and attempt suicide. Suicidal thoughts and ideations in paramedics have been compared to the general population, with one study indicating a lifetime prevalence rate of 28% for feeling life is not worth living, 10% for serious suicidal ideation, and three percent for a past suicide attempt. ^{Reference Stanley, Hom and Joiner4} Other reports have shown that prehospital personnel tend to think more about suicide and to attempt it more compared to the general population. ¹⁷

Having both paramedic and firefighting duties has been associated with a six-fold increase in the likelihood of reporting a suicide attempt as compared to firefighting alone. ^{Reference Stanley, Hom and Joiner4} In a separate study, 37% of paramedic and fire professionals had contemplated suicide, nearly ten-times the rate of the comparable general population. In addition, nearly seven percent had reported a suicide attempt compared with just 0.5 percent of the general population. ^{Reference Abbot, Barber and Burke13} These rates put first responders overall at a higher risk of suicide than the general public. ^{Reference Henderson, van Hasselt, LeDuc and Couwels27}

Evidence suggests that firefighters may be more likely to think about and attempt suicide than the general population; however, these studies are limited by their use of convenience sampling. ^{Reference Stanley, Hom and Joiner4} In a convenience sample of 1,027 current and retired US firefighters, the prevalence of suicidal ideation was nearly 47%, suicide planning was 19%, and suicide attempts was nearly 16% as compared to lifetime rates of ideations, plans, and attempts (13.5%, 3.9%, and 4.6%, respectively) among the general US population. ^{Reference Stanley, Hom, Hagan and Joiner30} In a national sample of firefighters, posttraumatic stress symptoms were associated with firefighters having a 5.2-times higher likelihood of attempting suicide compared to the general public. ^{Reference Boffa, Stanley, Hom, Norr, Joiner and Schmidt31}

In a literature review of suicide and suicidal ideation among police officers, the lifetime prevalence of suicidal ideation was found to be 25% for female police officers and 23% in male officers, with suicide attempt rates ranging from less than one percent to 55% among different studies. ^{Reference Stanley, Hom and Joiner4} Another study linked the strain associated with the first responder job to suicidal ideation, as well as depression and anger. Police officers with burnout showed significantly greater suicide risk with officers who reported burnout at work also reporting a 117% greater likelihood of suicidal thoughts. ^{Reference Bishopp and Boots32} A further study found that more firefighters and police officers died by suicide than in the line of duty. The same study found that PTSD and depression can be almost five-times as high among firefighters and police officers than the general public. ^{Reference Heyman, Dill and Douglas28}

Supporting Mental Health and Well-Being during the First Responder Career

Given this well-established evidence-base which highlights the increased risk first responders have for poor mental health and compromised well-being, it is important to understand the interventions that have been developed to support mental health for these groups. Furthermore, it is with urgency that there is a need to determine the evidence-base under-pinning these programs so that evidence-informed decisions can be made when it comes to policy and practice.

However, the evidence-base remains under-developed. As Kleim and Westphal noted in their review of mental health in first responders:

There is a similar lack of knowledge about how best to teach these prevention skills to first responders. ^{Reference McCreary5}

What is known about mental ill health prevention programs for first responders is that published evidence supporting interventions (such as what programs exist, the objectives of the programs, and what the programs actually include) is sparse. Additionally, if there are any interventions being implemented among first responder organizations, there have been limited objective evaluations conducted and published on their effectiveness. ^{Reference McCreary5} This lack of primary information results in a subsequent lack of high-level evidence syntheses, including systematic reviews and meta-analyses, on which to guide knowledge-implementation decisions.

There have been some individual peer-reviewed studies which suggest that, like research on general workplace mental health support programs, the programs devised for first responders have not been helpful at reducing symptoms of poor mental health. ^{Reference McCreary5} An intervention focused on primary prevention was developed to reduce the negative health impact of work-related stress amongst police by enhancing officer’s sense of control over stress-provoking situations. Compared to a control group, the intervention group reported better overall levels of exhaustion and general well-being following the intervention. However, there was no assessment of symptoms for any specific types of mental ill health (eg, depression or PTSD), so it is not known if this would be an effective support program for preventing mental ill health. ^{Reference Arnetz, Arble, Backman, Lynch and Lublin33}

A randomized control trial of a sample of Australian firefighters examined the effectiveness of four one-hour training sessions on PTSD symptoms one year later. The experimental group received psychoeducation about PTSD and its impact on psychological health, as well as cognitive behavior therapy, support seeking, and self-soothing. The control group received regular training. The study findings indicated no beneficial effects of the intervention. ^{Reference Skeffington, Rees, Mazzucchelli and Kane34}

Addressing stigma remains an on-going barrier to supporting first responder mental health and well-being. Approximately 90% of respondents in one US-based study stated that stigma was a barrier to seeking treatment. ³⁵ The stigma associated with help-seeking is not limited to the US, it has also been reported in Australia, ³⁶ New Zealand, ^{Reference Peach37} and the United Kingdom. ^{Reference Stuart38} While some research on stigma in first responder groups has been undertaken, more research and data are needed to fully understand its relationship with help-seeking, coping, and health outcomes. ^{Reference Henderson, van Hasselt, LeDuc and Couwels27}

Another approach to improving first responder mental health is the development of resiliency-building programs. ^{Reference Spence39} Organizations can contribute to the promotion of personal resiliency through the creation of environments in which leaders encourage their personnel to make resiliency practices part of their daily routines. ^{Reference Hesketh40,Reference Hesketh41} Although limited in scope and depth, research on building resilience and positive mental health with first responders has shown some promising results. The evidence suggests that training in resilience building can significantly benefit first responder organizations by improving judgment and decision making and decreasing the frequency of on-the-job accidents. ^{Reference McCraty and Atkinson42}

Preliminary evaluations of resilience training used in Australia and Canada – Road to Mental Readiness (R2MR) – have shown promising results, with participants stating that it helps to reduce stigma and to build resiliency. They also found that the training was applicable in both their work and their personal lives. ⁴³ A further two US-based studies, although based on a small sample (n = 14 and n = 34), also found that resilience practices yielded positive results for first responders. ^{Reference Weltman, Lamon, Freedy and Chartrand44,Reference Ramey, Perkhounkova, Hein, Bohr and Anderson45} An Australian study investigated 143 first responders who participated in a six-session mindfulness training program. The results suggested that mindfulness-based resilience training delivered in an online format can create improvements in adaptive resilience among first responders. ^{Reference Joyce, Shand, Lal, Mott, Bryant and Harvey46}

A recent program developed to build first responder resilience and mental health is the Warr;or21 program. ^{Reference Thompson and Drew47} The program utilizes daily practices grounded in positive psychology and resilience over the course of 21 days. Each practice, including controlled breathing and gratitude, is evidence-based. A preliminary evaluation of the program (n = 61) revealed that program participants held very positive views of the program. Of the sample, 90% were very satisfied (60%) or satisfied (30%) with the program, and 95% of participants indicated that they would recommend the program to others in their profession. ^{Reference Thompson and Drew47}

Supporting Mental Health and Well-Being during the Retirement Transition

Specific training and support programs have been implemented by first responder organizations to help prepare new recruits for the risks associated with first responder careers. ^{Reference Sansbury, Graves and Scott48} Where many current support programs fall short is the absence of on-going support throughout the career and into retirement transition. Managers and leaders play an integral role in creating safe environments where conversations around mental health are normalized and programs supporting well-being become routine elements of programs designed to maintain overall first responder health.

Providing opportunities for appropriate debriefing and support are integral to supporting first responder mental health and well-being as they affect how first responders interpret and process stress. ^{Reference Prati and Pietrantoni49} The key is to encourage supportive workplaces that routinely make opportunities for staff to have conversations with a range of support providers, preferably encouraging a holistic approach to well-being, so that these relationships become a trusted and normal part of debriefing on a routine basis, as well as when staff are in crisis. The importance of having someone in their organization that they built a rapport with throughout their career cannot be emphasized enough. Having these normalized well-being support structures in place prior to first responder staff transitioning into retirement will ultimately assist in keeping staff mentally healthy and happy throughout, and after, their career. ^{Reference Prati and Pietrantoni49}

Self-care is also vital when transitioning to retirement. Self-care as a process should be taught during training, encouraged throughout the career, and emphasized during retirement. ^{Reference Knight50} An example of an organization providing on-going training that emphasizes the importance of self-care techniques is “Yoga for First Responders.” This course teaches first responders how to stay calm under pressure and stress and equips them with the tools needed to manage being exposed to personal triggers and for self-regulation of emotion. Another Australian example is “Blind Tiger Yoga” which serves the veteran and emergency services community by teaching functional recovery tools to improve mindset, personal growth, and well-being. These types of self-care programs can help first responders transition from the stress of their job to a “normal” life at home and could likely be implemented to help with the transition to retirement. ^{Reference Kvitne51}

Retirement can be a challenging transition from any career. For first responders, there can be additional emotional and physical stress due to attachment to the job, making the transition into retirement extra challenging. ^{Reference Kragt, Jorritsma, Dunlop and Parker52} Police officers that had the smoothest transition to retirement viewed policing as “just a job,” their family system provided structure, and their organization provided the support they had become used to throughout their career. ^{Reference Ruiz and Morrow53} This further highlights the importance of embedding well-being support into first responder organizations on a routine basis, so that conversations around mental health become normal and the support available becomes a predictable and trusted presence throughout career into retirement.

One way to ease the stress associated with retirement transition is through first responder organizations providing programs that prepare employees for retirement, even several years before they reach retirement age. ^{Reference Kragt, Jorritsma, Dunlop and Parker52} These retirement preparation programs should be evidence-based and include information about what age they are required to retire by, if there is an option to extend their retirement, and promote retirement as a positive, exciting, and inevitable life transition. ^{Reference Bracken-Scally, McGilloway and Mitchell54} Programs should also address the unique mental health and well-being challenges for first responders forced into early retirement, possibly due to ill health, and the needs of responders once they do retire.

Another way that first responder organizations can make the retirement transition smoother is by providing pre-retirement training to responders so that they can develop transferable skills that will aid them in finding other careers after they retire. ^{Reference Kragt, Jorritsma, Dunlop and Parker52} It would also be helpful if organizations offered services that help retired responders find a new job, if it is wanted, as well as a counselling program for themselves and their family members following retirement. ^{Reference Ruiz and Morrow53} Paramedics in Ireland have a transitional phase of “pre-retirement” as they adjust from working full-time to retiring. This type of approach allows responders to slowly reduce their hours over time, making the transition to retirement a smooth one. ^{Reference Bracken-Scally, McGilloway and Mitchell54} These kinds of initiatives can assist first responders to feel like they have not been “forgotten” once they turn in their uniforms.

When many first responders start their career, there is often a ceremony to recognize their recruitment and their commencement. Similar types of ceremonies to recognize retirement could be beneficial in supporting the on-going mental health and well-being of first responders exiting the workforce. Some responders may favor a more formal retirement ceremony while others may prefer a more informal recognition with close friends and family. Regardless of the style, this is one idea that can help ease the transition period and thank responders for many years of service. ^{Reference Kragt, Jorritsma, Dunlop and Parker52,Reference Ruiz and Morrow53}

For many responders, wearing a uniform and being part of an emergency response team will be intricately linked with their identify. Once that uniform is handed in and they do not routinely see the same teammates, responders can begin to question their identity and place in the post-first-responder world. Readjusting to civilian life can be challenging, an experience also had by many military veterans. Military service can be difficult, demanding, and dangerous. But returning to civilian life also poses challenges for the men and women who have served in the armed forces. A survey of 1,853 veterans found that while 72% had an easy time readjusting to civilian life, 27% reported that re-entry was difficult for them. This proportion swelled to 44% among veterans who served in the 10 years since the 9/11 terrorist attacks. ⁵⁵

According to the study, veterans who had a clear understanding of their role and contributions while serving experienced fewer difficulties transitioning into civilian life compared to those who did not. In contrast, veterans who reported having an emotionally traumatic experience while serving or had suffered a serious service-related injury were significantly more likely to report problems with re-entry. The lingering consequences of experiencing psychological trauma while on the job are particularly striking. The probabilities of an easy re-entry for veterans dropped from 82% for those who did not experience a traumatic event to 56% for those who did. ⁵⁵

Even small traumatic events can have a big impact. As first responders progress through their careers, each incident, each traumatic experience goes into their emotional backpacks as a rock. Over the years, they struggle to function wearing this heavy load, yet they continue to add rock after rock. ^{Reference Heglund56} Over an extended period, stressors and traumatic experiences can take a toll. Mental and emotional fatigue was a factor in 28% of absenteeism within police organizations. ⁴³

The only other people who will really understand the weight of these backpacks are other responders. Another important option for supporting first responders in retirement is through the formation of organizational groups specific to their career as first responders. These retirement groups can assist in ensuring that first responders do not feel isolated and alone upon their retirement, and they can provide on-going support and connection, both integral to protecting mental health and well-being of first responder retirees. These groups could offer voluntary welfare programs, social meetings, and gatherings to retired responders. ^{Reference Ruiz and Morrow53,Reference Bracken-Scally, McGilloway and Mitchell54}

Heglund ^{Reference Heglund56} writes about the importance of taking a holistic approach to mental health and well-being, advocating for the use of retreat-based programs which utilize a range of skilled and experienced clinical and peer staff specifically trained in trauma recovery. Australian research provides further support for adopting this holistic, retreat-based approach to supporting mental health and well-being of first responders. ^{Reference Dean57}

Advocating for early-intervention to assist in the prevention of mental ill health, this research highlighted that while clinical therapies seem to be useful in short-term treatment, they do not provide the tools or strategies required to make the lifestyle changes needed to sustain improved mental health and well-being in the long-term, including into retirement. Examples of holistic, retreat-based programs for first responders include the West Coast Post Trauma Retreat (WCPR) in the US, ⁵⁸ which is a residential program providing an educational experience designed to help current and retired first responders recognize the signs and symptoms of work-related stress including PTSD; and the Badge of Life Canada Program in Canada, which includes a peer group of first responders with PTSD spending a week together engaging in discussion, physical activity yoga, and equine therapy. ⁵⁹