Sleep Disturbance Among Firefighters: Understanding Associations with Alcohol Use and Distress Tolerance

The Cyclical Battle of Insomnia and Mental Health Impairment in Firefighters: A Narrative Review

The occupational requirements of full-time non-administrative firefighters include shift-work schedules and chronic exposure to alerting emergency alarms, hazardous working conditions, and psychologically traumatic events that they must attend and respond to. These compiling and enduring aspects of the career increase the firefighter's risk for insomnia and mental health conditions compared to the general population. Poor sleep quality and mental health impairments are known to coincide with and contribute to the symptom severity of one another. Thus, it is important to determine approaches that may improve sleep and/or mental health specifically for firefighters, as their occupation varies in many aspects from any other occupation. This review will discuss symptoms of insomnia and mental health conditions such as PTSD, anxiety, depression, substance abuse, and suicide in firefighters. The influencing factors of sleep and mental health will be examined including anxiety sensitivity, emotional regulation, and distress tolerance. Current sleep and mental health interventions specific to full-time firefighters are limited in number; however, the existing experimental studies will be outlined. Lastly, this review will provide support for exploring exercise as a possible intervention that may benefit the sleep and mental health of this population.

Associations between Sleep Disturbance and Suicidal Ideation Severity in Iranian University Students: Evaluating Emotion Regulation Difficulties and Distress Tolerance

AIM

Although sleep disturbance is associated with suicide ideation, underlying cognitive-affective mechanisms that may explain this association are not well understood. The aim of the present study was to concurrently evaluate whether emotion regulation difficulties and distress tolerance explain this association among Iranian university students.

METHOD

A total of 679 Iranian university students (66.42% females; Mage = 24.34 years, SD = 4.86) completed a battery of online self-report questionnaire. Structural equation modeling was used to empirically explore the relations among variables.

RESULTS

Sleep disturbance was positively associated with suicide ideation. Higher sleep disturbance symptoms were associated with higher levels of suicide ideation. Sleep disturbance was indirectly related to suicide ideation through both emotion regulation difficulties and distress tolerance.

CONCLUSION

Findings expand knowledge of cognitive-emotional processes that may explain the sleep disturbance-suicide ideation association among Iranian university students. Iranian students experiencing sleep disturbance may benefit from intervention strategies targeting emotion regulation skills and distress tolerance to reduce suicide ideation.

Global prevalence and associated factors of sleep disorders and poor sleep quality among firefighters: A systematic review and meta-analysis

Lack of sleep can affect the health and performance of firefighters. This systematic review and meta-analysis estimated the global prevalence of sleep disorders and poor sleep quality among firefighters and reported associated factors. Four academic databases (Scopus, PubMed, Web of Science, and Embase) were systematically searched from January 1, 2000 to January 24, 2022. These databases were selected as they are known to index studies in this field. The search algorithm included two groups of keywords and all possible combinations of these words. The first group included keywords related to sleep and the second group keywords related to the firefighting profession. The relevant Joanna Briggs Institute checklist was used to evaluate study quality. Data from eligible studies were included in a meta-analysis. In total, 47 articles informed this review. The pooled prevalence of sleep disorders and poor sleep quality in firefighters were determined as 30.49% (95% CI [25.90, 35.06]) and 51.43% (95% CI [42.76, 60.10]), respectively. The results of a subgroup analysis showed that individuals in low- and middle-income countries (LMICs) had a higher prevalence of sleep disorders than those in high-income countries (HICs) but HICs had a higher prevalence of poor sleep quality than LMICs. Various factors, including shift work, mental health, injuries and pain, and body mass index were associated with sleep health. The findings of this review highlight the need for sleep health promotion programs in firefighters.

Working hours, sleep, and fatigue in the public safety sector: A scoping review of the research

BACKGROUND

The public safety sector includes law enforcement officers (LEO), corrections officers (CO), firefighter service (FF), wildland firefighting (WFF), and emergency medical services (EMS), as defined in the National Occupational Research Agenda (NORA) of the National Institute for Occupational Safety and Health (NIOSH). Across these occupations, shiftwork, long-duration shifts, and excessive overtime are common. Our objective was to identify research gaps related to working hours, sleep, and fatigue among these workers.

METHODS

We used a scoping review study design that included searches of MEDLINE, Embase, CAB Abstracts, Global Health, PsychInfo, CINAHL, Scopus, Academic Search Complete, Agricultural and Environmental Science Collection, ProQuest Central, Cochrane Library, Safety Lit, Homeland Security Digital Library, and Sociological Abstracts using a range of occupational search terms and terms related to working hours, sleep, and fatigue.

RESULTS

Out of 3415 articles returned from our database search, 202 met all inclusion criteria. Six common outcomes related to working hours, sleep, and fatigue emerged: sleep, fatigue, work performance, injury, psychosocial stress, and chronic disease. Nearly two-thirds (59%, n = 120) of the studies were observational, of which 64% (n = 77) were cross sectional and 9% were (n = 11) longitudinal; 14% (n = 30) of the studies were reviews; and 19% (n = 39) were experimental or quasi-experimental studies. Only 25 of the 202 articles described mitigation strategies or interventions. FFs, LEOs, EMS, and WFFs were the most studied, followed by COs.

CONCLUSIONS

In general, more longitudinal and experimental studies are needed to enrich the knowledge base on the consequences of long working hours, poor sleep, and fatigue in the public safety sector. Few experimental studies have tested novel approaches to fatigue mitigation in diverse sectors of public safety. This gap in research limits the decisions that may be made by employers to address fatigue as a threat to public-safety worker health and safety.

Fatigue sensitivity and mental health among trauma-exposed firefighters

Background

Firefighters are faced with numerous work-related demands and stressors, including exposure to potentially traumatic events, and are thus at an increased risk for poor mental health outcomes. To better understand the mental health of trauma-exposed firefighters, the current study sought to examine the association of fatigue sensitivity with posttraumatic stress disorder (PTSD), anxiety, and depressive symptom severity in a cross-sectional study design.

Methods

Participants included 107 (M _age = 40.8 years; SD _age = 8.95; age range: 21-67 years; 95.0% male) trauma-exposed firefighters.

Results

Findings from the current study indicated that fatigue sensitivity was a statistically significant clinical correlate of PTSD, anxiety, and depressive symptom severity. The statistically significant incremental effects were small to medium across the mental health variables, but evident after accounting for years in the fire service, sleep quality, and trauma load.

Conclusions

The present data provide initial empirical evidence for the role of fatigue sensitivity in terms of a broad range of mental health indices among trauma-exposed firefighters.

Distress tolerance across substance use, eating, and borderline personality disorders: A meta-analysis

BACKGROUND

Distress tolerance (DT) has received increased attention in recent years due to its purported role in dysregulated behaviours and their clinical manifestations, such as problematic substance use (PSU), disordered eating behaviours (e.g., binge-eating and purging; DEB), and borderline personality disorder (BPD) symptomatology. Despite the proposed transdiagnostic utility of DT across PSU, DEB, and BPD, there has yet to be a systematic and comprehensive examination characterising and comparing its association with this class of impulsive-type psychopathology.

METHODS

A systematic search was conducted across five electronic databases using search terms designed to capture extant literature on the association between DT and PSU, DEB, and BPD symptomatology. A series of meta-analyses were undertaken on correlation coefficients from 81 studies to examine the association between DT and each psychopathology domain, as well as impulsive-type psychopathology overall. Moderator analyses were conducted to examine whether these relationships were moderated by DT measurement type, sample type, age, and gender.

RESULTS

DT shared significant, negative, medium correlations with PSU (r = -.18,), DEB (r = -.20), and BPD symptomatology (r = -.27). The magnitude of these associations was not significantly different across the three psychopathology domains, supporting transdiagnostic conceptualisation. DT measurement type, age, and sample type moderated several of these indicated relationships.

LIMITATIONS

The majority of studies were conducted in adult samples from Western countries, limiting understanding of these relationships across development and different cultures.

CONCLUSIONS

The present findings support the putative transdiagnostic role of DT across PSU, DEB, and BPD, which may ultimately inform novel, cross-cutting interventions.

Firefighter sleep: a pilot study of the agreement between actigraphy and self-reported sleep measures

STUDY OBJECTIVES

The aim of this study is to determine the extent of agreement between self-reported measurements of total sleep time (TST) and actigraphy in the fire and emergency services occupation.

METHODS

Twenty-four firefighters participated in an 18-day study. Four measurements were used to assess TST: Pittsburgh Sleep Quality Index, a newly developed habitual Extended Sleep Survey, a newly developed daily Emergency Services Sleep Diary (ESSD), and actigraphy. The Extended Sleep Survey and ESSD were constructed to address the specific job-related characteristics of fire and emergency services that other measurements cannot achieve (eg, multiple sleep episode in a single night).

RESULTS

The Pittsburgh Sleep Quality Index TST is least accurate compared to actigraphy. The Extended Sleep Survey TST shows improvement over Pittsburgh Sleep Quality Index TST, but was statistically different from actigraphy TST. No difference in mean TST was found between ESSD TST and actigraphy TST. Furthermore, ESSD TST and actigraphy TST correlated strongly together.

CONCLUSIONS

Without modification, traditional self-reported measures may not be appropriate in the fire and emergency service occupation. This study suggests that the ESSD may serve as a useful alternative to actigraphy to measure TST.

CITATION

Billings JM. Firefighter sleep: a pilot study of the agreement between actigraphy and self-reported sleep measures. J Clin Sleep Med. 2022;18(1):109-117.

Mental Health of Canadian Firefighters: The Impact of Sleep

Volunteer and career firefighters are at risk of major depressive disorders, posttraumatic stress disorder (PTSD), alcohol use disorder, and other mental health disorders due to the demanding and unpredictable nature of their employment. The mental health risks are exacerbated by the need to work extended hours, night shifts, and/or rotating schedules, or the competing demands of other employment, especially in volunteer firefighters. The mental health disorders and risk factors interact with altered sleeping patterns. In the current study, we examined volunteer and career firefighters regarding the association between mental health and sleep, drawing from a national Canadian mental health survey of 1217 firefighters. Most (69%) of the firefighters reported less than ideal sleep quality and 21% screened positive for clinical insomnia, with no significant difference between volunteer and career subgroups. Firefighters with insomnia had higher odds ratios (OR) and frequencies for PTSD (OR = 4.98), generalized anxiety disorder (OR = 7.15), panic disorder (OR = 6.88), social phobia (OR = 4.98), and major depressive disorder (OR = 7.91), than firefighters without insomnia. The burden of sleep disorders and their association with mental health disorders suggests that sleep should be considered in health monitoring and self-management, environmental design, fire service work-organization policies, and health programming.

Occupational Stress and Burnout in the Fire Service: Examining the Complex Role and Impact of Sleep Health

The occupational stress inherent in firefighting poses both physiological and psychological risks to firefighters that have been found to possess a reciprocal nature. That is, the nature of these relationships in terms of indicator and impact are elusive, especially as it relates to sleep health (e.g., quality, quantity, hygiene, etc.) as a specific physiological risk and burnout as a specific psychological risk. A series of mediation models were assessed to examine the reciprocal relationships between occupational stress, burnout, and sleep health in a sample of 161 career firefighters. The mediation models confirmed reciprocity among the variables in so much that relationships were best described by the underlying mechanism at work. Comprehensive assessments of both subjective and objective markers of sleep health should be incorporated into firefighter research to supplement behavioral health assessments and interventions, especially related to burnout and occupational stress.

Mental Health Correlates of Probable Posttraumatic Stress Disorder, Probable Alcohol Use Disorder, and Their Co-Occurrence among Firefighters

Firefighters demonstrate high rates of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Research has yet to compare how these diagnoses and their co-occurrence relate to firefighter mental health. This study evaluated trauma load, PTSD, alcohol use, depression, sleep, suicide risk, anger, and occupational stress across four discrete groups of firefighters (N = 660): (1) trauma-exposed only (n = 471), (2) probable PTSD-only (n = 36), (3) probable AUD-only (n = 125), and (4) probable PTSD-AUD (n = 28). Firefighters completed an online survey. Firefighters with probable PTSD-AUD demonstrated higher scores on all criterion variables, except trauma load, compared to firefighters with probable AUD-only or trauma-only. Firefighters with probable PTSD-AUD and probable PTSD-only reported similar levels of all indices, except alcohol use severity and suicide risk, which were higher among the probable PTSD-AUD group. Results provide preliminary empirical evidence of the deleterious impact of PTSD-AUD comorbidity among firefighters.

Pandemic-related mental health risk among front line personnel

The mental health of frontline workers is critical to a community's ability to manage crises and disasters. This study assessed risks for mental health problems (traumatic stress, depression, anxiety, alcohol use, insomnia) in association with pandemic-related stressors in a sample of emergency and hospital personnel (N = 571). Respondents completed self-report surveys online from April 1st to May 7th, 2020 in the Rocky Mountain region of the United States. Results showed that roughly fifteen to thirty percent of respondents screened positive for each disorder. Odds of screening positive were similar between groups for probable acute traumatic stress, depressive disorder, anxiety disorder, and alcohol use disorder; emergency personnel reported significantly higher rates of insufficient sleep than healthcare workers. Logistic regressions showed that respondents who reported having an immunocompromised condition had higher odds of acute traumatic stress, anxiety, and depression. Having an immunocompromised household member was associated with higher odds of insufficient sleep and anxiety. Being in a direct care provision role was associated with higher odds of screening positive for risky alcohol use. Being in a management role over direct care providers was associated with higher odds of screening positive for anxiety, risky alcohol use, and insufficient sleep. There was an inverse relationship between number of positive COVID-19 cases and anxiety, such that as positive cases went up, anxiety decreased. Overall, the mental health risks that we observed early in the COVID-19 pandemic are elevated above previous viral outbreaks (SARS) and comparable to rates shown in disasters (9/11 attacks; Hurricane Katrina).

Do Criminals Live Faster Than Soldiers and Firefighters? : A Comparison of Biodemographic and Psychosocial Dimensions of Life History Theory

A high risk of morbidity-mortality caused by a harsh and unpredictable environment is considered to be associated with a fast life history (LH) strategy, commonly linked with criminal behavior. However, offenders are not the only group with a high exposure to extrinsic morbidity-mortality. In the present study, we investigated the LH strategies employed by two groups of Polish men: incarcerated offenders (N = 84) as well as soldiers and firefighters (N = 117), whose professions involve an elevated risk of injury and premature death. The subjects were asked to complete the Mini-K (used as a psychosocial LH indicator) and a questionnaire which included a number of biodemographic LH variables. Although biodemographic and psychosocial LH indicators should be closely linked with each other, the actual connection between them is unclear. Thus, this study was driven by two aims: comparing LH strategies in two groups of men with a high risk of premature morbidity-mortality and investigating the relationship between the biodemographic and psychosocial LH dimensions. The study showed that incarcerated men employed faster LH strategies than soldiers and firefighters, but only in relation to biodemographic variables (e.g., number of siblings, age of sexual initiation, life expectancy). No intergroup differences emerged regarding psychosocial LH indicators. Moreover, the correlation analysis showed a weak association between biodemographic and psychosocial LH indicators. The results strengthen the legitimacy of incorporating biodemographic LH traits into research models and indicate the need for further research on the accuracy of the Mini-K. The possible explanations for the intergroup differences in LH strategies are discussed.