Exposure to traumatic incidents and prevalence of posttraumatic stress symptomatology in urban firefighters in two countries

Risk Factors Associated with Suicidal Ideation and Suicidal Behavior in Wildland Firefighters

INTRODUCTION

Wildland firefighters are posited to have a higher suicide rate than general firefighters and the general population. However, the rates and risk factors of suicide among wildland firefighters is not fully understood.

METHODS

For this preregistered study, 564 participants were recruited from Facebook to obtain a final sample of 246 participants with valid data who were current or former wildland firefighters in the United States. Participants completed online measures of suicidal ideation, history of suicidal behaviors, posttraumatic stress disorder (PTSD) symptoms, problematic alcohol use, and occupational exposure to suicide.

RESULTS

In this sample, 22% of wildland firefighters reported a history of at least one suicide attempt, and 36.7% reported current suicidal ideation. PTSD symptoms, but not problematic alcohol use or exposure to suicide, were positively associated with suicidal ideation and a history of suicide attempts. Additionally, PTSD symptoms explained significantly more variance in suicidal ideation than depression symptoms alone.

CONCLUSIONS

Wildland firefighters demonstrate rates of suicide attempts that exceed those of non-wildland firefighters and of the general population at large. In addition, PTSD symptoms may contribute to suicidal thoughts and behaviors (STB) in this population. This is the largest study of STB in wildland firefighters to date.

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.

Evaluation of the Implementation of the NFFF Stress First Aid Intervention in Career Fire Departments: A Cluster Randomized Controlled Trial

Firefighting is inherently dangerous, though recently concerns have shifted from traditional fireground injuries (burns and asphyxiation) to a focus on mental and behavioral health. Although firefighters are remarkably resilient, research suggests many suffer negative psychological consequences from repeated exposures to trauma. While the Stress First Aid (SFA) model has gained increased attention and adoption among fire departments as a model for behavioral health training, it has not been formally evaluated. This cluster randomized controlled trial used a crossover design comparing the immediate SFA group to delayed SFA control to test the impact of the SFA on firefighters' mental and behavioral health changes after 10-12 months (n = 400; Mage = 37.6, 4.8% women). A convenience sample of 79 firefighters (Mage = 41.4; 8.7% women) provided evaluations on one or more of the training modules. Participants reported satisfaction with all training components (Peer team training 97.6%, Online SFA 94.9%, Curbside Manner 88.4%, After Action Review 89.4%) and reported success in changing personnel's perception of their department's ability to respond to behavioral health issues (SFA M = 3.93, Control 3.50; t = 2.52, p = 0.042). Future work should focus on additional resources and training to augment existing efforts to help departments continue their efforts.

Duty-related trauma and PTSD symptoms in US urban firefighters

BACKGROUND

Little is known about the multi-dimensional nature of traumatic duty-related events encountered by firefighters in relation to their post-traumatic stress disorder (PTSD) risk.

AIMS

To describe the types of duty-related events encountered by career firefighters and explore if years in the fire service or total event load moderated the association of trauma exposure to PTSD symptoms.

METHODS

Participants included 755 career, male firefighters (19% of the department's firefighters and 76% of those who accessed the electronic anonymous survey). The Duty-Related Incident Stressors scale was used to assess exposure to 25 potentially traumatic events (event load) and self-appraisal of the stress associated with these events, grouped by type of event (indirect, direct and colleague-related). The Post-Traumatic Stress Disorder Checklist was used to assess PTSD symptoms.

RESULTS

Firefighters rated colleague-related events as the most stressful, followed by indirect and direct events. Event load (r = 0.25) and indirect, direct and colleague-related events stress (r = 0.32-0.35) were positively associated with PTSD symptoms. Results of moderation analyses indicated that event load served as a risk factor in the relation of indirect events stress to PTSD symptoms, and as a buffer in the relation of direct events stress to PTSD symptoms. Years in the fire service were not associated with PTSD symptoms nor moderated the relation of event stress to PTSD symptoms.

CONCLUSIONS

Findings underscored the importance of considering the differential effects that types of duty-related traumatic events and cumulative exposure to trauma may have on firefighters' PTSD symptoms.

Potentially Psychologically Traumatic Event Exposure Histories of new Royal Canadian Mounted Police Cadets

OBJECTIVE

Royal Canadian Mounted Police (RCMP) report extremely frequent and varied exposures to potentially psychologically traumatic events (PPTEs). While occupational exposures to PPTEs may be one explanation for the symptoms of mental disorders prevalent among serving RCMP, exposures occurring prior to service may also play a role. The objective of the current study was to provide estimates of lifetime PPTE exposures among RCMP cadets in training and assess for associations with mental disorders or sociodemographic variables.

METHODS

RCMP cadets (n  =  772; 72.0% male) beginning the Cadet Training Program (CTP) completed a survey assessing self-reported PPTE exposures as measured by the Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition-Extended. Binomial tests were conducted to compare the current results to previously collected data from the general population, a diverse sample of public safety personnel (PSP) and serving RCMP.

RESULTS

Cadets reported statistically significantly fewer PPTE exposures for all PPTE types than serving RCMP (all p's < 0.001) and PSP (all p's < 0.001) but more PPTE exposures for all PPTE types than the general population (all p's < 0.001). Cadets also endorsed fewer PPTE types (6.00  ±  4.47) than serving RCMP (11.64  ±  3.40; p < 0.001) and other PSP (11.08  ±  3.23) but more types than the general population (2.31  ±  2.33; p < 0.001). Participants who reported being exposed to any PPTE type reported the exposures occurred 1-5 times (29.1% of participants), 6-10 times (18.3%) or 10  +  times (43.1%) before starting the CTP. Several PPTE types were associated with positive screens for one or more mental disorders. There were associations between PPTE types and increased odds of screening positive for post-traumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD) and social anxiety disorder (SAD) (all p's < 0.05). Serious transport accident (11.1%), physical assault (9.5%) and sudden accidental death (8.4%) were the PPTEs most identified as the worst event, and all were associated with positive screens for one or more mental disorders.

CONCLUSION

The current results provide the first information describing PPTE histories of cadets, evidencing exposure frequencies and types much higher than the general population. PPTE exposures may have contributed to the cadet's vocational choices. The current results support the growing evidence that PPTEs can be associated with diverse mental disorders; however, the results also suggest cadets may be uncommonly resilient, based on how few screened positive for mental disorders, despite reporting higher frequencies of PPTE exposures prior to CTP than the general population.

Ultra-brief training in cognitive reappraisal or mindfulness reduces anxiety and improves motor performance efficiency under stress

BACKGROUND AND OBJECTIVES

We examined the effects of ultra-brief training in mindfulness and cognitive reappraisal on affective response and performance under stress. We hypothesized that one or both types of training would decrease affective responding and improve performance, and that these effects might be moderated by acute stress induction.

DESIGN

We manipulated training (mindfulness, cognitive reappraisal, control) between subjects and level of stress (low, high) within subjects in a 3 × 2 mixed factorial design. Method: Participants (N = 112, ages 18-35) completed two sessions on different days. In each session, they received mindfulness or cognitive reappraisal training or listened to a control script prior to a low- or high-stress simulated hostage situation. We measured motor performance efficiency (proportion of shots that hit hostile and hostage targets), affective responding (self-reported anxiety, salivary cortisol and alpha amylase, and autonomic physiology), and physical activity.

RESULTS

Compared to control instructions, ultra-brief training in cognitive reappraisal or mindfulness reduced subjective anxiety and increased performance efficiency. There were few effects of training on other measures.

CONCLUSION

Ultra-brief training in cognitive reappraisal or mindfulness prior to a stressful task may be both helpful and harmful; effects are preliminary and subject to boundary conditions.

Sleep Latency and Post-Traumatic Stress Disorder Among Retired Career Florida Firefighters: Evidence From the Advancing Epidemiology of Retired Firefighters Aging Longitudinally Cohort

OBJECTIVE

Our objective was to estimate the association of post-traumatic stress disorder (PTSD) and sleep latency among retired firefighters.

METHODS

Baseline health survey data collected from retried career Florida firefighters participating in an ongoing prospective cohort study from 2017 to 2021 were analyzed. Risk for PTSD was assessed using a four-item primary care PTSD screening construct, and sleep onset latency was assessed by self-reported length of time to fall asleep.

RESULTS

Among the 500 participants, 8.0% screened positive for PTSD risk and 37.6% had prolonged sleep onset latency (≥20 minutes to fall asleep). Retired firefighters with PTSD risk were 2.7 times more likely (adjusted odds ratio, 2.70; 95% confidence interval, 1.27-5.75) to have prolonged sleep latency compared with those without PTSD risk while controlling for covariates.

CONCLUSIONS

Retired firefighters who screen positive for PTSD risk are three times more likely to report delayed sleep onset latency.

Mental Health Among Firefighters: Understanding the Mental Health Risks, Treatment Barriers, and Coping Strategies

BACKGROUND

Firefighters are at high-risk of mental health. This study qualitatively assessed the pathways toward mental health in firefighters.

METHODS

A two-phased assessment was conducted incorporating in-depth interviews (n = 52) and 10 focus group discussions (n = 82) with firefighters. Thematic analysis was used to develop codes and themes that informed the development of a conceptual model.

RESULTS

Firefighters recognized personalizing events by relating calls to their personal lives or prior life experiences as the main risk factor. Department debriefing with fire chiefs or leadership after traumatic events was reported as the primary coping strategy firefighters found most effective. Stigma and lack of medical professionals understanding the firefighter culture were identified as barriers for accessing mental health services or their effectiveness.

DISCUSSION

Pathways toward mental health in firefighters were identified that could be used to improve current strategies to protect their well-being.

Association of War Zone-Related Stress With Alterations in Limbic Gray Matter Microstructure

IMPORTANCE

Military service members returning from theaters of war are at increased risk for mental illness, but despite high prevalence and substantial individual and societal burden, the underlying pathomechanisms remain largely unknown. Exposure to high levels of emotional stress in theaters of war and mild traumatic brain injury (mTBI) are presumed factors associated with risk for the development of mental disorders.

OBJECTIVE

To investigate (1) whether war zone-related stress is associated with microstructural alterations in limbic gray matter (GM) independent of mental disorders common in this population, (2) whether associations between war zone-related stress and limbic GM microstructure are modulated by a history of mTBI, and (3) whether alterations in limbic GM microstructure are associated with neuropsychological functioning.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was part of the TRACTS (Translational Research Center for TBI and Stress Disorders) study, which took place in 2010 to 2014 at the Veterans Affair Rehabilitation Research and Development TBI National Network Research Center. Participants included male veterans (aged 18-65 years) with available diffusion tensor imaging data enrolled in the TRACTS study. Data analysis was performed between December 2017 to September 2021.

EXPOSURES

The Deployment Risk and Resilience Inventory (DRRI) was used to measure exposure to war zone-related stress. The Boston Assessment of TBI-Lifetime was used to assess history of mTBI. Stroop Inhibition (Stroop-IN) and Inhibition/Switching (Stroop-IS) Total Error Scaled Scores were used to assess executive or attentional control functions.

MAIN OUTCOMES AND MEASURES

Diffusion characteristics (fractional anisotropy of tissue [FAT]) of 16 limbic and paralimbic GM regions and measures of functional outcome.

RESULTS

Among 384 male veterans recruited, 168 (mean [SD] age, 31.4 [7.4] years) were analyzed. Greater war zone-related stress was associated with lower FAT in the cingulate (DRRI-combat left: P = .002, partial r = -0.289; DRRI-combat right: P = .02, partial r = -0.216; DRRI-aftermath left: P = .004, partial r = -0.281; DRRI-aftermath right: P = .02, partial r = -0.219), orbitofrontal (DRRI-combat left medial orbitofrontal cortex: P = .02, partial r = -0.222; DRRI-combat right medial orbitofrontal cortex: P = .005, partial r = -0.256; DRRI-aftermath left medial orbitofrontal cortex: P = .02, partial r = -0.214; DRRI-aftermath right medial orbitofrontal cortex: P = .005, partial r = -0.260; DRRI-aftermath right lateral orbitofrontal cortex: P = .03, partial r = -0.196), and parahippocampal (DRRI-aftermath right: P = .03, partial r = -0.191) gyrus, as well as with higher FAT in the amygdala-hippocampus complex (DRRI-combat: P = .005, partial r = 0.254; DRRI-aftermath: P = .02, partial r = 0.223). Lower FAT in the cingulate-orbitofrontal gyri was associated with impaired response inhibition (Stroop-IS left cingulate: P < .001, partial r = -0.440; Stroop-IS right cingulate: P < .001, partial r = -0.372; Stroop-IS left medial orbitofrontal cortex: P < .001, partial r = -0.304; Stroop-IS right medial orbitofrontal cortex: P < .001, partial r = -0.340; Stroop-IN left cingulate: P < .001, partial r = -0.421; Stroop-IN right cingulate: P < .001, partial r = -0.300; Stroop-IN left medial orbitofrontal cortex: P = .01, partial r = -0.223; Stroop-IN right medial orbitofrontal cortex: P < .001, partial r = -0.343), whereas higher FAT in the mesial temporal regions was associated with improved short-term memory and processing speed (left amygdala-hippocampus complex: P < .001, partial r = -0.574; right amygdala-hippocampus complex: P < .001, partial r = 0.645; short-term memory left amygdala-hippocampus complex: P < .001, partial r = 0.570; short-term memory right amygdala-hippocampus complex: P < .001, partial r = 0.633). A history of mTBI did not modulate the association between war zone-related stress and GM diffusion.

CONCLUSIONS AND RELEVANCE

This study revealed an association between war zone-related stress and alteration of limbic GM microstructure, which was associated with cognitive functioning. These results suggest that altered limbic GM microstructure may underlie the deleterious outcomes of war zone-related stress on brain health. Military service members may benefit from early therapeutic interventions after deployment to a war zone.

Conceptualizing Suicide Prevention in Firefighters Through the lens of the Interpersonal-Psychological Theory of Suicide: A Narrative Review

Suicide is the 10th leading cause of death in the United States and is a significant public health problem. Suicide has also become a major concern among career American firefighters with rates for suicidal ideation and attempts in firefighters two to three times higher than rates in the general population. Firefighter suicide and mental health are major issues facing fire service leaders, mental health professionals, and most recently suicide experts. Despite an increased focus on understanding suicide in the fire service, there is little empirical evidence on the effectiveness of prevention in this population. The juxtaposition of elevated suicide rates with a dearth of empirical prevention data specific to firefighters warrants new approaches and conceptualizations of suicide prevention in this population. Grounded in the framework of the interpersonal-psychological theory of suicide (IPTS), this narrative review integrates select relevant firefighter specific suicide risk/protective factors and multi-level intervention/prevention literature to provide a structured approach to identifying current suicide intervention/prevention efforts with promising transportability to firefighters. Several recommendations for future intervention research specific to firefighters are also proposed.

Preventative Care in First Responder Mental Health: Focusing on Access and Utilization via Stepped Telehealth Care

First responders are at high risk for disorders that arise from repeat exposure to stress and trauma (Post Traumatic Stress Disorder, depression, and problematic alcohol use). Although mental health treatments are available, first responders often do not access them, anchored by barriers that include: lack of knowledge, stigma, negative experience with mental health providers, and time-based burdens. In this study, we designed an intervention to address these barriers, extending a Planned-Action framework. Step 1 involved self-report screening for four mental health risks (PTSD, depression, anxiety, and alcohol use risk), delivered to all personnel electronically, who were free to either consent and participate or opt-out. The detection of risk(s) in Step 1 led to scheduling a Step 2 telehealth appointment with a trained clinician. We report descriptive statistics for participation/attrition/utilization in Steps 1 and 2, rates of risk on four mental health variables, and rate of adherence to follow-up treatment recommendations. Step 1: In total, 53.3% of personnel [229 of 429 full-time employees (221 males; eight females; 95% White; 48% paramedic or Emergency Medical Technician; 25% captain; 19% engineer; 7% other)] initially opted-in by consenting and completing the brief remote screening survey. Among those who opted-in and completed (n = 229), 43% screened positive for one or more of the following mental health risks: PTSD (7.9%); depression (9.6%); anxiety (13.5%); alcohol use (36.7%). Step 2: A maximum of three attempts were made to schedule "at risk" individuals into Step 2 (n = 99). Among the 99 who demonstrated a need for mental health treatment (by screening positive for one or more risk), 56 (56.6%) engaged in the telehealth appointment. Of the 56 who participated in Step 2 clinical appointments, 38 were recommended for further intervention (16.6% of full-time personnel who participated). Among the 38 firefighters who were recommended to seek further mental health services, 29 were adherent/followed through (76.3% of those who received recommendations for further services). Taken together, evidence-based, culturally conscious, stepped care models delivered via the virtual/telehealth medium can promote access, utilization, and cost-effective mental health services for first responders. Implications are for informing larger, more rigorous dissemination and implementation efforts.

Mental Health Impacts of Wildfire, Flooding and COVID-19 on Fort McMurray School Board Staff and Other Employees: A Comparative Study

Background: Fort McMurray, a city in northern Alberta, Canada, has experienced multiple traumas in the last five years, including the 2016 wildfire, the 2020 floods, and the COVID-19 pandemic. Eighteen months after the wildfire, major depressive disorder (MDD), generalized anxiety disorder (GAD), and Post Traumatic Stress Disorder (PTSD) symptoms were elevated among school board employees in the city. Objective: This study aimed to compare employees of the school board and other employees of Fort McMurray in respect to the impact the 2016 wildfires, the 2019 COVID pandemic, and the 2020 floods had on their mental health. Methodology: A quantitative cross-sectional survey was conducted in Fort McMurray from 24 April to 2 June 2021. Online questionnaires were administered through REDCap and were designed to capture socio-demographic characteristics, clinical as well as wildfire, COVID-19, and flooding-related variables. Mental health outcome variables were captured using self-reported standardized assessment scales. Data were analysed with descriptive statistics, Chi-square/Fisher’s Exact tests, and binary regression analysis. Results: Of the 249 residents who accessed the online survey, 186 completed the survey, giving a response rate of 74.7%. Of these respondents, 93.5% (174) indicated their employment status and were included in the Chi-square analysis. Most of the respondents were female (86.2%, (150)), above 40 years (53.4%, (93)), and were in a relationship (71.3%, (124)). The prevalence values for MDD, GAD and PTSD among respondents were 42.4%, 41.0, and 36.8%, respectively. There was a statistically significant difference between employees of the school board and other employees with respect to likely PTSD prevalence (28% vs. 45%, respectively, p < 0.05), although with other factors controlled for, in a binary logistic regression model, employer type did not significantly predict likely PTSD. Conclusions: The study has established that likely PTSD symptoms were significantly higher in other employees compared to those of school board employees. Greater exposure to the traumatic events and a greater perceived lack of support from other employers might have contributed to the significantly higher prevalence of PTSD in other employees.

Relationship Between Posttraumatic Stress Symptoms and Cardiovascular Disease Risk in Firefighters

The impact of occupational stress on first responders has received increased investigative attention in recent years. However, research specifically targeting firefighters and their unique responses to job related stress remains limited. Although cardiovascular disease (CVD) risk has been recognized in firefighters, behavioral and psychological contributions (e.g., posttraumatic stress) have not been adequately examined. The purpose of this study was to: (1) examine the relationship between posttraumatic stress symptoms and CVD risk in firefighters, (2) assess the effects of service time on the relationship, and (3) increase understanding of the manifestations of stress in this population. Participants were 87 firefighters from Special Operations teams. Self-report measures of posttraumatic stress symptoms, health, and length of service were administered. Data from annual physical examinations provided information regarding CVD risk (weight, height, blood pressure, cholesterol, smoking, physical exercise). Results indicated significant relationships between posttraumatic stress symptomatology and current smoking status, triglyceride levels, and the number of CVD risk factors. Findings suggest that the presence of posttraumatic stress symptoms may influence overall CVD risk and may not be moderated by years of fire service. Implications for behavioral interventions with firefighters are discussed. Suggestions for future research in this area are offered.

Canadian Career Firefighters' Mental Health Impacts and Priorities

Firefighters' perceptions of mental health can inform management. This qualitative study explored Canadian career firefighters' experiences, needs, and research priorities with respect to mental health. Thirty-nine career firefighters (33 men, 6 women) of different ranks and geographic locales were interviewed using a semi-structured interview guide. The interviews were recorded, transcribed, and qualitatively analyzed using thematic analysis within an interpretive description approach. Firefighters reported that critical incidents and chronic job stressors contributed to mental health symptoms that led to burnout, compassion fatigue, and mental and physical injury. They were concerned with family impacts, like lack of full openness, reduced financial stability, and risk of divorce; and work impacts, like interpersonal conflict, lack of support to fellow firefighters, task avoidance, and absenteeism. A broad array of barriers and facilitators were found in firefighter work, culture, programs, social supports, health care, and societal factors. Variability in access to help, the changing fire service, and the complexity of knowing what to do to achieve mental health were evident across themes. Firefighters identified the need for research in four areas: awareness and monitoring, understanding etiology of mental health, better prevention and treatment, and access to care. Across domains of inquiry, context, "two sides to the coin", and uncertainty were overarching themes.

Here for My Peer: The Future of First Responder Mental Health

Workplace interventions that leverage social tactics to improve health and well-being are becoming more common. As an example, peer mental health support interventions aim to reduce stigma and promote treatment seeking in first responder populations. Given the social nature of these interventions, it is important to consider how the preexisting social context influences intervention outcomes. A peer mental health support intervention was delivered among first responders, and self-efficacy and intention to have supportive peer conversations were measured pre-and post-intervention. Trust in peers was measured prior to the intervention. Results suggest a floor effect may exist for self-efficacy, in which a foundational level of trust and pre-intervention self-efficacy may be needed to maximize intervention effectiveness. As the future of work brings complex safety and health challenges, collaborative solutions that engage multiple stakeholders (employees, their peers, and their organization) will be needed. This study suggests that more frequent attention to pre-existing intervention context, particularly social context in peer-focused intervention, will enhance intervention outcomes.

The Association of Sleep Disturbance and Suicide Risk Among Firefighters: Exploring Emotion Regulation Dimensions

AIM

This study explored the extent to which emotion regulation dimensions statistically mediate the association between sleep disturbance and suicide risk among firefighters.

METHOD

Participants were 865 firefighters working for a fire department in an urban area in the southern U.S. Bootstrapping was used to test the indirect effects of sleep disturbance on suicide risk through emotion regulation dimensions, after controlling for depression and trauma exposure.

RESULTS

The effect of sleep disturbance on suicide risk was significantly statistically mediated by emotion regulation difficulties (β= .09, SE = .02, 95% CI: .05, .14). Moreover, each of the five dimensions of emotion regulation difficulties significantly statistically mediated this association, with difficulties in engaging in goal-direct behavior (β = .09, SE = .02, 95% CI: .05, .14) and lack of strategies to reduce distress demonstrating the strongest indirect effects (β = .07, SE = .02, 95% CI: .04, .11), after accounting for depression and trauma exposure.

CONCLUSION

Results suggest that suicide interventions for firefighters who suffer from sleep disturbance should focus on the development of emotion regulation strategies.

Behavioral and Occupational Health in Military Firefighters: An Understudied Population

To our knowledge, no studies on health conditions in U.S. military firefighters exist. Data and demographics from the Defense Medical Epidemiology Database were analyzed on several shared medical issues among military personnel and civilian firefighters. Descriptive statistics and Chi-Square goodness of fit tests were conducted to support study aims. Between 2001 and 2015, substantial incidence rate increases (per 10,000) of tinnitus, PTSD, insomnia, and OSA (2005-2015) were observed. Modest to large increases in depressive disorders, adjustment reaction, generalized anxiety disorder, and panic disorder were observed. Decreasing rates were observed for alcohol dependence, hypertension, and tobacco use disorder. While efforts have examined the impact of sustained operations on military members, first responder military subgroups like firefighters are deficient. Cognitive Behavior Therapy interventions are efficacious for preventing and reducing behavioral health problems; therefore, tailoring them specifically for U.S. military firefighters could significantly improve quality of life and long-term health.

Compromised Conscience: A Scoping Review of Moral Injury Among Firefighters, Paramedics, and Police Officers

BACKGROUND

Public Safety Personnel (e.g., firefighters, paramedics, and police officers) are routinely exposed to human suffering and need to make quick, morally challenging decisions. Such decisions can affect their psychological wellbeing. Participating in or observing an event or situation that conflicts with personal values can potentially lead to the development of moral injury. Common stressors associated with moral injury include betrayal, inability to prevent death or harm, and ethical dilemmas. Potentially psychologically traumatic event exposures and post-traumatic stress disorder can be comorbid with moral injury; however, moral injury extends beyond fear to include spiritual, cognitive, emotional or existential struggles, which can produce feelings of severe shame, guilt, and anger.

OBJECTIVE

This scoping review was designed to identify the extant empirical research regarding the construct of moral injury, its associated constructs, and how it relates to moral distress in firefighters, paramedics, and police officers.

METHODS

A systematic literature search of peer-reviewed research was conducted using databases MEDLINE, EMBASE, APA PsychInfo, CINHAL PLUS, Web of Science, SCOPUS, and Google Scholar. Included studies were selected based on the inclusion criteria before being manually extracted and independently screened by two reviewers.

RESULTS

The initial database search returned 777 articles, 506 of which remained after removal of duplicates. Following review of titles, abstracts, and full texts, 32 studies were included in the current review. Participants in the articles were primarily police officers, with fewer articles focusing on paramedics and firefighters. There were two studies that included mixed populations (i.e., one study with police officers, firefighters, and other emergency service workers; one study with paramedic and firefighter incident commanders). Most studies were qualitative and focused on four topics: values, ethical decision-making, organizational betrayal, and spirituality.

CONCLUSION

Public safety organizations appear to recognize the experience of moral distress or moral injury among public safety personnel that results from disconnects between personal core values, formal and informal organizational values, vocational duties, and expectations. Further research is needed to better understand moral distress or moral injury specific to public safety personnel and inform training and treatment in support of public safety personnel mental health.

Predictors of PTSD and CPTSD in UK firefighters

Background: Globally, professional firefighters are often exposed to traumatic events and are at high risk of developing posttraumatic stress disorder (PTSD) symptoms. Objective: With the publication of the 11th edition of the International Classification of Diseases (ICD-11) there arose a need for research based on the new diagnostic criteria, and the associated disorder, Complex PTSD (CPTSD). Method: Participants were 1300 former or present firefighters from the UK. Prevalence rates of PTSD and CPTSD were estimated using International Trauma Questionnaire in accordance with ICD-11 criteria, and service related and personal trauma exposure were also assessed using an anonymous online questionnaire. Multinomial logistic regression was performed to assess how service and personal trauma exposure predicted PTSD and CPTSD. Results: CPTSD criteria were met by 18.23% (95% CI 16.13-20.33%) and PTSD criteria were met by 5.62% (95% CI 4.37-6.87%) of the sample. Experiencing higher levels of service-related trauma significantly increased the risk for both PTSD and CPTSD, and nonwork related trauma uniquely predicted CPTSD but not PTSD. Conclusions: This study provided the first examination of the new ICD-11 criteria for PTSD and CPTSD in a large sample of firefighters, and CPTSD was more common than PTSD. Exposure to multiple different types of trauma increased the odds of PTSD and CPTSD.

An epidemiologic study of suicide among firefighters: Findings from the National Violent Death Reporting System, 2003 - 2017

Suicide is a significant concern among fire service due to high rates of suicide behaviors. The aim of this study was to describe suicides among firefighters using national suicide death data. Data from the National Violent Death Reporting System for 722 firefighters and 192,430 non-firefighters were analyzed to compare sociodemographics and risk factors between firefighter and non-firefighter decedents; and among firefighters based on suicide means. A greater proportion of firefighter decedents died by firearm compared to non-firefighters. Firefighter decedents were less likely to have been diagnosed with depression, but more likely to have been diagnosed with post-traumatic stress disorder compared to non-firefighters. A greater percentage of firefighter decedents had a relationship or physical health problem prior to death, but a lower percentage had a history of suicide thoughts/attempts. Among firefighter decedents, multivariate analysis showed physical health problems and disclosing suicide intent predicted death by firearm. Greater awareness of risk factors, reduced access to lethal means, and ensuring access to behavioral health services may aide in decreasing suicide mortality in this population. These findings should be interpreted with caution due to limitations concerning report accuracy, generalizability, small female sample size, and inclusion of data only for lethal suicide attempts.

Diversity, preventive work and education-matters of health and well-being in firefighter discourse

Purpose: The aim of this study is to analyse how recurrent health hindrance themes in the firefighter discourse, identified by firefighters themselves, relate to a set of policies about diversity, preventive work and education of firefighters. The intention is further to discuss the implications of these policy initiatives and the resistance against them in terms of firefighters' health and well-being at work. Method: Firefighters from three different rescue stations in Sweden, participated in either a focus group discussion or individual interviews. Different themes in firefighter discourse that were described as hindrances to the health and well-being of firefighters were identified. A strategic sample of policy documents that relate to the very same themes was also chosen for analysis and here we combined critical discourse analysis (CDA) with critical policy analysis. Results: The health hindrance themes regarding diversity, preventive work and education that firefighters identified have in common that they relate to changes in work culture and the firefighter profession. Conclusion: In conclusion, we argue that the most important challenge for the rescue service to tackle in the future, is how to transform firefighting to be more inclusive and yet maintaining the good health and well-being that exists among the vast majority of today's firefighters.

The Development of a Sleep Intervention for Firefighters: The FIT-IN (Firefighter's Therapy for Insomnia and Nightmares) Study

Background: Firefighters are vulnerable to irregular sleep patterns and sleep disturbance due to work characteristics such as shift work and frequent dispatch. However, there are few studies investigating intervention targeting sleep for firefighters. This preliminary study aimed to develop and test a sleep intervention, namely FIT-IN (Firefighter’s Therapy for Insomnia and Nightmares), which was based on existing evidence-based treatment tailored to firefighters in consideration of their occupational characteristics. Methods: This study implemented a single-group pre-post study design, utilizing an intervention developed based on brief behavior therapy for insomnia with imagery rehearsal therapy components. FIT-IN consisted of a total of three sessions (two face-to-face group sessions and one telephone session). Participants were recruited from Korean fire stations, and a total of 39 firefighters participated. Participants completed a sleep diary for two weeks, as well as the following questionnaires to assess their sleep and psychological factors: insomnia severity index (ISI), disturbing dream and nightmare severity index (DDNSI), Epworth sleepiness scale (ESS), depressive symptom inventory-suicidality subscale (DSI), and Patient Health Questionnaire-9 (PHQ-9). These questionnaires were administered before the first session and at the end of the second session. Results: The FIT-IN program produced improvements in sleep indices. There was a significant increase in sleep efficiency (p < 0.01), and a decrease in sleep onset latency, number of awakenings, and time in bed (p < 0.05), as derived from weekly sleep diaries. In addition, significant decreases were shown for insomnia (p < 0.001) and nightmare severity (p < 0.01). Conclusion: There were significant improvements in sleep and other clinical indices (depression, PTSD scores) when comparing pre-and post-intervention scores. FIT-IN may be a feasible and practical option in alleviating sleep disturbance in this population. Further studies will be needed to ascertain FIT-IN’s effectiveness.

Emotional exhaustion and its relationship with suicide risk in emergency responders

The purpose of the current study was to evaluate the relationship between emotional exhaustion and suicide risk in emergency responders. Participants included 643 actively employed emergency responders who responded to an online research based survey. Participants were administered the Maslach Burnout Inventory (MBI; Maslach & Jackson, 1981) and the Suicide Behaviors Questionnaire (SBQ-R; Osman, Bagge, Gutierrez, Konick, Kooper, & Barrios, 2001). Using a categorical measure of emotional exhaustion, responders reported a statistically significant increased suicide risk [F(2, 640) = 45.01, p < .001] between levels of emotional exhaustion. Post hoc analysis confirmed significant differences between each level of emotional exhaustion with a significant increase of risk at each category (Low [M = 4.60, SD= 2.38], Moderate [M = 5.56, SD= 2.50], High [M = 6.95, SD= 3.26]). Emergency responders with high levels of emotional exhaustion had an average suicide risk score approaching the significant risk cut-off of 7.

PTSD and post-traumatic stress spectrum in the Italian Navy Operational Divers Group and corps of Coast Guard Divers employed in search and rescue activities in the Mediterranean refugees emergences and Costa Concordia shipwreck

Rescue personnel is at high risk for Post-traumatic Stress Disorder (PTSD) because of the possible repetitive exposition to "cruel details of traumatic events" (DSM-5). Literature reported PTSD rates in combat exposed veterans, although the Italian Navy military personnel has been frequently involved in no-war activities in most recent years, such as Search and Rescue (SAR) activities of civilians involved in catastrophic events. The study aimed at exploring the prevalence of PTSD and its impact on social and work functioning among divers of the Italian Navy employed in the SAR activities for the Costa Concordia shipwreck (2012), the collapsed control tower of the Genoa harbour (2013), and the "Mare Nostrum" and "Triton" immigrant emergency Operations in the Mediterranean Sea. The 85 Italian Navy and Coast Guard Divers on duty for these activities were involved in the study and forty fulfilled the assessments, including the: Impact Event Scale (IES-r), Trauma and Loss Spectrum Self-Report (TALS-SR) and Work and Social Adjustment Scale (WSAS). In the three years before enrollment 77.5% of the sample (n = 31) performed at least one rescue operation, with full and partial DSM-5 PTSD rates being 7.5% and 22.5%, respectively. A correlation emerged between WSAS domains or total scores and TALS-SR score domains for PTSD. Rescue Navy personnel resulted to be at risk for post-traumatic stress symptoms, and these subthreshold PTSD manifestations appear to impact on functioning. Further studies are needed to better investigate PTSD risk and resilience factors in this particular group of workers.

Strain Differences in Responsiveness to Repeated Restraint Stress Affect Remote Contextual Fear Memory and Blood Transcriptomics

The role of stress in altering fear memory is not well understood. Since individual variations in stress reactivity exist, and stress alters fear memory, exposing individuals with differing stress-reactivity to repeated stress would affect their fear memory to various degrees. We explored this question using the average stress-reactive Fisher 344 (F344) rat strain and the Wistar-Kyoto (WKY) strain with its heightened stress-reactivity. Male F344 and WKY rats were exposed to the contextual fear conditioning (CFC) paradigm and then chronic restraint stress (CRS) or no stress (NS) was administered for two weeks before a second CFC. Both recent and reinstated fear memory were greater in F344s than WKYs, regardless of the stress status. In contrast, remote memory was attenuated only in F344s after CRS. In determining whether this strain-specific response to CRS was mirrored by transcriptomic changes in the blood, RNA sequencing was carried out. Overlapping differentially expressed genes (DEGs) between NS and CRS in the blood of F344 and WKY suggest a convergence of stress-related molecular mechanisms, independent of stress-reactivity. In contrast, DEGs unique to the F344 and the WKY stress responses are divergent in their functionality and networks, beyond that of strain differences in their non-stressed state. These results suggest that in some individuals chronic or repeated stress, different from the original fear memory-provoking stress, can attenuate prior fear memory. Furthermore, the novel blood DEGs can report on the general state of stress of the individual, or can be associated with individual variation in stress-responsiveness.

PTSD symptoms and suicidal ideation in US female firefighters

BACKGROUND

Little is known regarding the mental health of women firefighters.

AIMS

To identify demographic, work-related and mental health characteristics associated with post-traumatic stress disorder (PTSD) symptoms and lifetime suicidal ideation in female firefighters compared with male colleagues.

METHODS

Participants were firefighters (75 women and 2564 men) employed in a large urban fire department in the USA. Chi-square, correlations, t-tests and analyses of variance were conducted to examine the predictors of PTSD symptoms and lifetime suicide ideation in men and women.

RESULTS

Approximately 20% of women scored positively for PTSD and 30% reported lifetime suicidal ideation. Women with PTSD symptoms were more likely to be in their mid-career years (11-20) than in their first 10 years (87% versus 44%; χ2 = 8.77, P < 0.05) and to have received counselling (53% versus 14%; χ2 = 8.11, P < 0.01). Being single (73% versus 58%; χ2 = 6.02, P < 0.05), having a second job (68% versus 38%; χ2 = 5.79, P < 0.05) and having received counselling (41% versus 11%; χ2 = 8.51, P < 0.01) predicted suicide ideation. Depression and general stress positively predicted PTSD symptoms and suicide ideation. PTSD also predicted suicide ideation.

CONCLUSIONS

Compared to male firefighters, women were at high risk for PTSD symptoms and suicide ideation. Particularly for women, few socio-demographic and work-related variables were associated with these outcomes. Mental health variables predicted depression and suicide ideation for both gender groups. Therefore, in screening and intervention efforts, it may be most fruitful to focus on mental health risk correlates of PTSD and suicide ideation.

Mental Disorders in Firefighters Following Large-Scale Disaster

Firefighting service is known to involve high rates of exposure to potentially traumatic situations, and research on mental health in firefighting populations is of critical importance in understanding the impact of occupational exposure. To date, the literature concerning prevalence of trauma-related mental disorders such as posttraumatic stress disorder (PTSD) has not distinguished between symptomology associated routine duty-related exposure and exposure to large-scale disaster. The present systematic review synthesizes a heterogeneous cross-national literature on large-scale disaster exposure in firefighters and provides support for the hypothesis that the prevalence of PTSD, major depressive disorder, and anxiety disorders are elevated in firefighters compared with rates observed in the general population. In addition, we conducted narrative synthesis concerning several commonly assessed predictive factors for disorder and found that sociodemographic factors appear to bear a weak relationship to mental disorder, while incident-related factors, such as severity and duration of disaster exposure, bear a stronger and more consistent relationship to the development of PTSD and depression in cross-national samples. Future work should expand on these preliminary findings to better understand the impact of disaster exposure in firefighting personnel.

Heart Rate Variability and Accelerometry as Classification Tools for Monitoring Perceived Stress Levels-A Pilot Study on Firefighters

Chronic stress is the main cause of health problems in high-risk jobs. Wearable sensors can become an ecologically valid method of stress level assessment in real-life applications. We sought to determine a non-invasive technique for objective stress monitoring. Data were collected from firefighters during 24-h shifts using sensor belts equipped with a dry-lead electrocardiograph (ECG) and a three-axial accelerometer. Levels of stress experienced during fire incidents were evaluated via a brief self-assessment questionnaire. Types of physical activity were distinguished basing on accelerometer readings, and heart rate variability (HRV) time series were segmented accordingly into corresponding fragments. Those segments were classified as stress/no-stress conditions. Receiver Operating Characteristic (ROC) analysis showed true positive classification as stress condition for 15% of incidents (while maintaining almost zero False Positive Rate), which parallels the amount of truly stressful incidents reported in the questionnaires. These results show a firm correspondence between the perceived stress level and physiological data. Psychophysiological measurements are reliable indicators of stress even in ecological settings and appear promising for chronic stress monitoring in high-risk jobs, such as firefighting.

The "Managed" or Damaged Heart? Emotional Labor, Gender, and Posttraumatic Stressors Predict Workplace Event-Related Acute Changes in Cortisol, Oxytocin, and Heart Rate Variability

Vital to the everyday operation of police services, police communicators (911 call-takers and dispatchers) are persistently subject to imminent challenges in the workplace; they must always be prepared to engage and deal with a wide variety of circumstances that provoke various intense emotions and physiological stress responses. Acute changes in cortisol, oxytocin, and heart rate variability are central to adaptive responses in stressful complex social interactions, but they might also be indicative of physiological dysregulation due to long-term psychosocial stress exposures. Thus, we examine acute stress-induced release of peripheral oxytocin and cortisol along with changes in heart rate variability, and how each relates to persistent workplace stressors and symptoms of posttraumatic stress. Findings indicate chronic forms of gendered workplace stress such as emotional labor, gender role stress and, posttraumatic stress each have differential associations with, and predict physiological responses to, acutely stressful events in the workplace. These associations suggest potential mechanisms through which communicators become more vulnerable to developing stress-related disorders such as posttraumatic stress injuries, especially after cumulative traumatic exposures in this context. The results also suggest potential pathways for the biological embedding of stressful gendered workplace experiences.

Coping and Its Relation to PTSD in Greek Firefighters

Firefighters are exposed continuously to intense stress situations and traumatic incidents, and are at high risk of developing posttraumatic stress disorder (PTSD). Coping mechanisms and behaviors have been examined as factors contributing to PTSD. The strategies that may be used to cope with stress and/or trauma differ between individuals and also between different professions and traumatic events (). Although there is a vast literature on stress and coping processes that exists, very few studies investigated the way individual firefighters cope with trauma. Among several questionnaires that have been used to examine the effects of different types of coping mechanisms after traumatic incidents is the Albert Einstein College of Medicine-Coping Style Questionnaire (AECOM-CSQ; ). In August 2007, large areas in the Peloponnese, Greece, were devastated by wildfires. One month after the event, experienced researchers visited the affected area to provide psychological support and to investigate the psychosocial consequences among the local professional firefighters. One hundred two firefighters that were on duty for the entire period of firefighting (several days) were interviewed using several questionnaires, among them the AECOM-CSQ. Our hypothesis was that firefighters who presented with PTSD would be more inclined toward engaging in avoidance coping mechanisms. A total of 18.6% of the firefighters were found to have PTSD according to ICD-10 criteria. Logistic regression showed that firefighters using the coping mechanisms of minimization and blame were associated with the greater likelihood of PTSD. It seems that specific coping mechanisms used by firefighters immediately after the traumatic event might contribute to the development of PTSD.

Structural and Resting-State Brain Alterations in Trauma-Exposed Firefighters: Preliminary Results

Purpose

To analyze the altered brain regions and intrinsic brain activity patterns in trauma-exposed firefighters without posttraumatic stress disorder (PTSD).

Materials and Methods

Resting-state functional MRI (rsfMRI) was performed for all subjects. Thirty-one firefighters over 40 years of age without PTSD (31 men; mean age, 49.8 ± 4.7 years) were included. Twenty-six non-traumatized healthy controls (HCs) (26 men; mean age, 65.3 ± 7.84 years) were also included. Voxel-based morphometry was performed to investigate focal differences in the brain anatomy. Seed-based functional connectivity analysis was performed to investigate differences in spontaneous brain characteristics.

Results

The mean z-scores of the Seoul Verbal Learning Test for immediate and delayed recall, Controlled Oral Word Association Test (COWAT) score for animals, and COWAT phonemic fluency were significantly lower in the firefighter group than in the HCs, indicating decreased neurocognitive function. Compared to HCs, firefighters showed reduced gray matter volume in the left superior parietal gyrus and left inferior temporal gyrus. Further, in contrast to HCs, firefighters showed alterations in rsfMRI values in multiple regions, including the fusiform gyrus and cerebellum.

Conclusion

Structural and resting-state functional abnormalities in the brain may be useful imaging biomarkers for identifying alterations in trauma-exposed firefighters without PTSD.

Chronic social disruption following a systemic fishery failure

In the United States, the iconic groundfish fishery for Gulf of Maine cod has endured several dramatic reductions in annual catch limits and been federally declared an economic disaster. Using a repeated cross-sectional survey of fishing captains to assess potential social impacts of the fishery failure, we found that psychological distress and social disruption were pervasive throughout New England fishing communities. For instance, our results indicate that 62% of captains self-reported severe or moderate psychological distress 1 y after the crisis began, and these patterns have persisted for 5 y. Using classification tree analyses, we found that low levels of trust in fisheries management was the most powerful predictor of both initial and chronic psychological distress. Distress was most severe among individuals without income diversity and those with dependents in the household. Compared to other aspects of fisheries, measuring and managing for noneconomic social outcomes and human well-being has lagged behind, even though it is a necessary component of mitigating the adverse impacts of fisheries disruptions.

A SWOT Analysis of the Field of Virtual Reality for Firefighter Training

Virtual reality (VR) research has gone through rapid advances and the technology has established itself as a valuable training tool in many domains. While research in the field of emergency response, and more specifically in the field of firefighting, is still catching up, the future potential of VR technology for training is promising. This paper uses the SWOT framework to analyse the strengths, weaknesses, opportunities, and threats immersive VR technology faces in the field of firefighter training. While using VR for training is cost-effective, safe to use and provides the ability to prepare trainees with a large variety of high fidelity training environments, the lack in specialization of the applications for the fire-service sector and issues with technology acceptance and limitations need to be addressed. Looking to current research, there are promising findings that might be directly transferable, creating affective, and multi-sensory experiences for more effective mental and physical training of firefighters in the future. More research is needed to establish methods of skills transfer from VR to real life scenarios and to evaluate the potential risk of frequent training in engaging and physiologically stimulating virtual environments.

Management of post-traumatic stress disorder: A protocol for a multiple treatment comparison meta-analysis of randomized controlled trials

BACKGROUND

Most systematic reviews have explored the efficacy of treatments on symptoms associated with post-traumatic stress disorder (PTSD), which is a chronic and often disabling condition. Previous network meta-analysis (NMA) had limitations such as focusing on pharmacological or psychotherapies. Our review is aims to explore the relative effectiveness of both pharmacological and psychotherapies and we will establish the differential efficacy of interventions for PTSD in consideration of both symptom reduction and functional recovery.

METHODS

We will conduct a network meta-analysis of randomized controlled trials evaluating treatment interventions for PTSD. We will systematically search Medline, PILOT, Embase, CINHAL, AMED, Psychinfo, Health Star, DARE and CENTRAL to identify trials that: (1) enroll adult patients with PTSD, and (2) randomize them to alternative interventions or an intervention and a placebo/sham arm. Independent reviewers will screen trials for eligibility, assess risk of bias using a modified Cochrane instrument, and extract data. Our outcomes of interest include PTSD symptom reduction, quality of life, functional recovery, social and occupational impairment, return to work and all-cause drop outs.

RESULTS

We will conduct frequentist random-effects network meta-analysis to assess relative effects of competing interventions. We will use a priori hypotheses to explore heterogeneity between studies, and assess the certainty of evidence using the GRADE approach.

CONCLUSION

This network meta-analysis will determine the comparative effectiveness of therapeutic options for PTSD on both symptom reduction and functional recovery. Our results will be helpful to clinicians and patients with PTSD, by providing a high-quality evidence synthesis to guide shared-care decision making.

Perceived social support functions as a resilience in buffering the impact of trauma exposure on PTSD symptoms via intrusive rumination and entrapment in firefighters

Resilience has been highlighted as a pivotal factor in overcoming the detrimental impact of trauma. The present study tests a resilience model of trauma using risk (rumination, emotion regulation, and entrapment) and protective (perceived social support) factors in a sample of firefighters who are at heightened risk for post-traumatic stress disorder, using a cross-sectional design. Specifically, the present study focuses on perceived social support as a resilience factor against PTSD symptoms, in response to trauma exposure. The sample included 545 firefighters from six large cities in Korea, who completed the following self-report questionnaires: Life Event Checklist, Event-related Rumination Inventory, Emotion Regulation Questionnaire, Entrapment scale, Impact of Event Scale-Revised, and Duke-UNC Functional Social Support Questionnaire. Exposure to traumatic events indirectly affected PTSD symptoms via intrusive rumination, emotional regulation, and perceptions of entrapment. Additionally, the mediating effects of intrusive rumination and perceptions of entrapment were moderated by perceived social support. That is, firefighters with high levels of perceived social support reported lower severity of rumination and PTSD symptoms. These findings suggest that perceptions of social support may operate as a resilience factor in buffering the effects of trauma on PTSD symptoms. Perceived social support interacts with intrusive rumination and perceptions of entrapment, thereby resisting the development of PTSD symptoms.

PTSD symptom severity and impulsivity among firefighters: Associations with alcohol use

Firefighters represent a unique population at high risk for trauma exposure, posttraumatic stress disorder (PTSD), and alcohol use. This study explored the main and interactive effects of PTSD symptom severity and impulsivity with regard to alcohol use severity. We hypothesized that higher levels of PTSD symptom severity and impulsivity would be related to greater alcohol use severity. Covariates included trauma load, depressive symptom severity, and romantic relationship status. The sample was comprised of 654 firefighters (Mage = 38.65, SD = 8.60) who endorsed exposure to potentially traumatic events and lifetime alcohol use. Firefighters completed an online questionnaire battery. A series of hierarchical regressions was conducted. PTSD symptom severity and impulsivity were significantly, incrementally associated with alcohol use severity, and a significant interactive effect was documented; firefighters with heightened PTSD symptom severity and impulsivity had the highest levels of alcohol use severity. This line of inquiry has great potential to inform prevention and intervention efforts for this vulnerable population. Clinical and research implications are discussed.

Social Support Outside the Workplace, Coping Styles, and Burnout in a Cohort of EMS Providers From Minnesota

Occupational burnout has been linked to the delivery of lower quality of care in some health care professions, including with turnover intentions and absenteeism in emergency medical services (EMS) workers. Thus, studies that identify factors associated with burnout may be integral to optimizing quality and workforce engagement among EMS professionals. A survey was conducted to assess social support outside the workplace, coping styles, and occupational burnout in a cohort of EMS providers from Minnesota. Surveys were returned by 217 providers (54% response), of which 167 had provided data on burnout, social support, and coping styles and were included in the analysis. The mean age was 41 years, 62% were male, and the prevalence of burnout was 17%. After adjustment for age and EMS tenure, the odds of burnout was higher among those characterized as socially isolated as compared with providers who were integrated socially or moderately integrated (odds ratio = 3.52; 95% confidence interval = [1.13, 10.98]). Common coping responses included planning, positive reframing, and active coping, while behavioral disengagement and denial were rarely used. Lack of social networks outside the workplace and frequent use of self-blame, food, or substance use as coping strategies were associated with burnout. Conversely, social integration and use of religion and instrumental support to cope with stressors were associated with reduced burnout.

Conceptualization, Assessment, and Treatment of Traumatic Stress in First Responders: A Review of Critical Issues

First responders are regularly confronted with exposure to traumatic events, including potentially life-threatening situations as well as the grave injuries and deaths of colleagues and civilians. Evidence indicates that the prevalence of posttraumatic stress disorder (PTSD) is substantially higher among first responders than the general population. This article provides information about the outpatient trauma services at McLean Hospital's LEADER (Law Enforcement, Active Duty, Emergency Responder) program to assist clinicians who encounter these first responders in their practices or who are specifically interested in working with this patient population. We begin by synthesizing the literature on the prevalence of PTSD in first responders following work-related exposure to traumatic stress, and by addressing the occupation-specific risk factors and the third-variable risk factors that may contribute to potentiated risk. We then discuss assessment strategies and treatment options used in our program, which is tailored for individuals who are dealing with mental health issues stemming from occupation-specific traumatic-stress exposure. We also address the unique challenges of treating traumatized first responders with more complex issues such as traumatic stress exposure across the lifespan and safety issues, including acute suicidality. We conclude by discussing notable gaps in the literature, including the need to investigate why and how women present with different PTSD symptoms than men and how these differences need to be taken into account in determining appropriate treatment for women.

Role of Student Nurse in the Prehospital Medical Teams Responding to the Scene of A Terrorist Attack in France

BACKGROUND

The terrorist attacks in Paris and in Saint-Denis in November 2015 were unprecedented events involving various human and material resources. These events question the role of nurse students in prehospital teams.

PURPOSE

To investigate nursing students' preference about whether they wished to participate in the prehospital care during a terrorist attack.

METHODS

This cross-sectional study was conducted with student nurses, from two nursing schools in the Greater Paris area. They completed an anonymous survey assessing the desire to be called to help the mobile intensive care units (MICU) or another ward; whether their presence should be mandatory, and the feelings associated with their experience. The responses were collected with a visual analogue scale and could range from 1 (yes, very much) to 10 (no, not at all). A Chi-square test was performed for qualitative variables and a Mann-Whitney test for quantitative variables.

FINDINGS

Among 225 students, 205 (91%) responded, 133 (65%) were women. When on duty, 169 (82%) would have preferred to accompany the MICU team, compared with 31 (15%) who would have preferred not to go. Overall, 146 students (71%) considered that this presence should be optional. Only gender was significantly associated with the choice to accompany the MICU team (W = 87% vs. M = 13%; p = .002). Students expressed a moderate feeling of frustration and fear.

DISCUSSION

Students would prefer to assist the MICU team responding to the scene of a terrorist attack but feel this choice should be optional. A discussion in nursing schools and universities should be considered for the implementation of a "systematic" procedure to ensure the student's willingness to participate in such interventions.