The impact of traumatic stressors in civilian occupational settings

Social support utilization's effect on post-traumatic stress symptoms: a Danish cross-sectional study of 383 ambulance personnel

Introduction

Social support is considered an important factor in prevention of mental illness. However, little is known about the association between ambulance personnel's use of multiple types of social support and post-traumatic stress symptoms (PTSS). This study aims to assess if number of used social support types predicts PTSS for ambulance personnel. Apart from assessing the main effect of social support utilization, we were interested in investigating if social support utilization moderated the effect of frequency of critical events on PTSS.

Materials and methods

A total of 383 ambulance personnel completed a survey consisting of validated questionnaires. Hierarchical multiple linear regression analyses were performed to assess the association between frequency of traumatic exposure and utilization of social support and PTSS as outcome variable.

Results

Higher number of utilized social support types was associated with higher levels of PTSS (β = 0.15, p <.001). When serving as a moderator of the association between frequency of exposure to critical incidents and PTSS, social support utilization had a significant and positive interaction effect (β = 0.26, p = .049). 307 participants had used 2 or 3 types of informal support during the past year, whereas 81 had used 2 or 3 types of formal support.

Conclusion

To our knowledge, this is the first study investigating the relationship between utilization of multiple, concurrent social support types and PTSS. This study suggests that to understand the effects of social support among ambulance personnel, it is necessary to assess the utilization of multiple concurrent support types, contributing factors to social support use, and different patterns of social support utilization that constitutes professional life in ambulance work.

The recovery processes among paramedics who encountered violence during work-a narrative interview study

BACKGROUND

Almost all paramedics encounter workplace violence (WPV) during their careers. The most common form of WPV is verbal, and the perpetrator is usually the patient. It is known that paramedics suffer from post-traumatic stress disorder and other mental health problems, and WPV is one of the reasons behind that. Nevertheless, little is known about the recovery processes paramedics have had after encountering WPV. The research question was: What kind of recovery processes have paramedics had after encountering WPV?

METHODS

A qualitative, narrative interview study was done. Data was collected in individual interviews with Finnish paramedics (n = 18). Paramedics were from different parts of Finland, and their ages varied from 24 to 49 years. They had been working in EMS for an average of 10.5 years (range 1.5 to 25 years). Interviews were conducted with a narrative approach, which enabled paramedics to narrate their experiences and speak on their own terms about the subject to the extent of their choosing. The data was analyzed using thematic analysis.

RESULTS

Ten recovery process themes were identified: Strong psychological and physical reactions in a short time frame, Questioning one's profession and actions, Various support structures aided in recovery, Dysfunctional processes hindered recovery, Personal resources provided support, The support of the workcommunity as a lifeline, Left to cope alone, Permanent changes to work routines, Resulting in professional growth and Eternal crack in the shell.

CONCLUSIONS

Many internal and external factors affect paramedics' recovery processes. While some receive adequate help, others struggle to get appropriate support, especially from their organization and supervisors. The findings of this study suggest that clear protocols should be established to help paramedics recover after encountering WPV and that an individual aspect should be kept in mind, as not everybody reacts in the same way.

Longitudinal assessment of psychological distress and its determinants in a sample of firefighters based in Montreal, Canada

Introduction

Firefighters face elevated risks of common mental health issues, with distress rates estimated at around 30%, surpassing those of many other occupational groups. While exposure to potentially traumatic events (PTEs) is a well-recognized risk factor, existing research acknowledges the need for a broader perspective encompassing multidimensional factors within the realm of occupational stress. Furthermore, this body of evidence heavily relies on cross-sectional studies. This study adopts an intensive longitudinal approach to assess psychological distress and its determinants among firefighters.

Methods

Participants were recruited from 67 fire stations in Montreal, Canada, meeting specific criteria: full-time employment, smartphone ownership, and recent exposure to at least one PTE, or first responder status. Subjects underwent a telephone interview and were directed to use an app to report depressive, post-traumatic, and generalized anxiety symptoms every 2 weeks, along with work-related stressors, social support, and coping styles. Analyses involved 274 participants, distinguishing between those exceeding clinical thresholds in at least one distress measure (the "distressed" subgroup) and those deemed "resilient." The duration and onset of distress were computed for the distressed group, and linear mixed models were employed to evaluate determinants for each psychological distress variable.

Results

Clinical psychological distress was observed in 20.7% of participants, marked by depressive, post-traumatic, and anxiety symptoms, often within the first 4-week reference period. Contextual factors (operational climate, social support, solitude) and individual factors (coping style, solitude and lifetime traumatic events in private life) exhibited more significant impacts on psychological distress than professional pressures within the firefighters' work environment.

Discussion

This study reports lower rates of psychological distress than previous research, possibly attributable to sample differences. It highlights that reported symptoms often represent a combined and transient layer of distress rather than diagnosable mental disorders. Additionally, determinants analysis underscores the importance of interpersonal relationships and coping mechanisms for mental health prevention interventions within this worker group. The findings carry implications for the development of prevention and support programs for firefighters and similar emergency workers.

Screening for Psychological Distress in Healthcare Workers Using Machine Learning: A Proof of Concept

The purpose of this study was to train and test preliminary models using two machine learning algorithms to identify healthcare workers at risk of developing anxiety, depression, and post-traumatic stress disorder. The study included data from a prospective cohort study of 816 healthcare workers collected using a mobile application during the first two waves of COVID-19. Each week, the participants responded to 11 questions and completed three screening questionnaires (one for anxiety, one for depression, and one for post-traumatic stress disorder). Then, the research team selected two questions (out of the 11), which were used with biological sex to identify whether scores on each screening questionnaire would be positive or negative. The analyses involved a fivefold cross-validation to test the accuracy of models based on logistic regression and support vector machines using cross-sectional and cumulative measures. The findings indicated that the models derived from the two questions and biological sex accurately identified screening scores for anxiety, depression, and post-traumatic stress disorders in 70% to 80% of cases. However, the positive predictive value never exceeded 50%, underlining the importance of collecting more data to train better models. Our proof of concept demonstrates the feasibility of using machine learning to develop novel models to screen for psychological distress in at-risk healthcare workers. Developing models with fewer questions may reduce burdens of active monitoring in practical settings by decreasing the weekly assessment duration.

Ensuring Optimal Mental Health Programs and Policies for First Responders: Opportunities and Challenges in One U.S. State

This study examined opportunities and challenges faced by individuals working to advance mental health policy and programming for first responders. We utilized qualitative content analysis and interviews with 16 firefighters, emergency medical services professionals, law enforcement officers, and others involved in programming or policy in the U.S. state of Ohio. Six themes characterized opportunities and challenges encountered: (1) variations in programming and policy exist across jurisdictions; (2) opportunities exist to enhance mental health awareness and self-care training for first responders; (3) need exists for specialized mental health clinicians accustomed to and capable of effectively working with first responders; (4) confidentiality protections are lacking for peer supporters not trained in critical incident stress management; (5) having an internal champion and broader support is key to program and policy advancement; and (6) interdepartmental collaboration provides opportunities for sharing resources and best practices. Results illustrate continued need for strategic policymaking, program development, and coordination.

Work-related posttraumatic stress disorder in paramedics in comparison to data from the general population of working age. A systematic review and meta-analysis

Objective

Paramedics are at particularly high risk for developing posttraumatic stress disorders (PTSD). Hitherto, evidence for higher prevalence rates in paramedics compared to the general population is vague. We aimed to determine and compare 12-month prevalence of PTSD in paramedics and general population from high-income countries.

Methods

We conducted systematic review processes to identify relevant studies for inclusion. For paramedics, we searched relevant databases, reference lists, and did citation tracking. Inclusion criteria were applied according to PICO. Quality of the studies was assessed using a validated methodological rating tool. Twelve-month prevalence data from all studies were pooled using random effects model. Subgroup analyses were performed to identify sources of heterogeneity.

Results

In total, we found 41 distinct samples with 17,045 paramedics, 55 samples with 311,547 individuals from non-exposed general population, 39 samples with 118,806 individuals from populations affected by natural disasters, and 22 samples with 99,222 individuals from populations affected by human-made disasters. Pooled 12-month prevalence estimates of PTSD were 20.0, 3.1, 15.6, and 12.0%, respectively. Prevalence estimates in paramedics varied with methodological quality and measurement instrument. Paramedics reporting distinct critical incidences had lower pooled prevalence than paramedics reporting indistinct types of exposure.

Conclusion

Paramedics have a pooled prevalence of PTSD that is considerably higher than rates of unexposed general population and populations affected by human-made disasters. Chronic exposure to low-threshold traumatic events during daily routine work is a risk factor for developing PTSD. Strategies to ensure long working lifetime are strongly needed.

Posttraumatic stress disorder and depression after the 2018 Strasbourg Christmas Market terrorist attack: a comparison of exposed and non-exposed police personnel

Background: Police personnel are among the first responders exposed to terrorist attacks, raising in number in the late decades. Due to their profession, they are also exposed to repetitive violence, increasing their vulnerability to PTSD and depression.Objective: Our study aims at comparing the prevalence of PTSD and depression, and the risk factors associated with these conditions among directly and indirectly exposed versus non-exposed police personnel during the Strasbourg Christmas Market terrorist attack.Method: Three months after the attack, participants completed a survey assessing their sociodemographic characteristics, occupational data, degree of exposure, sleep debt around the event, event centrality (CES), and three mental health conditions: PTSD (PCL-5), depression (PHQ-9), and suicide risk (yes/no questions).Results: A total of 475 police personnel responded to the questionnaire: 263 were exposed to the attack (182 of them directly) and 212 were non-exposed. Among directly exposed participants, the prevalences of partial and complete PTSD were 12.6 and 6.6%, and the prevalence of moderate-to-severe depression was 11.5%. Multivariate analysis revealed that direct exposure was associated with a higher risk of PTSD (OR = 2.98 [1.10-8.12], p = .03). Direct exposure was not associated with a higher risk of depression (OR = 0.40 [0.10-1.10], p = .08). A significant sleep debt after the event was not associated with a higher risk of later PTSD (OR = 2.18 [0.81-5.91], p = .13) but was associated with depression (OR = 7.92 [2.40-26.5], p < .001). A higher event centrality was associated with both PTSD and depression (p < .001).Conclusions: Police personnel directly exposed to the Strasbourg Christmas Market terrorist attack were at higher risk of PTSD but not depression. Efforts to prevent and treat PTSD should focus on directly exposed police personnel. However, general mental health should be monitored for every personnel member.

Effects of transcranial direct current stimulation (tDCS) in "Kiss nightclub fire" patients with post-traumatic stress disorder (PTSD): A phase II clinical trial

Objective

Considered the second biggest tragedy with fatal victims caused by fire, the Kiss nightclub fire tragedy that occurred in the interior of southern Brazil brought several problems to survivors. It is reported that 30-40% of victims of disasters can develop post-traumatic stress disorder. Application of repetitive transcranial magnetic stimulation has shown promising results in the treatment of post-traumatic stress disorder. Transcranial direct current stimulation similar to repetitive transcranial magnetic stimulation, a neuromodulation technique, has shown promise in treatment of neuropsychiatric disorders.

Method

A clinical trial was conducted from March 2015 to July 2016 in "KISS nightclub fire" disaster patients diagnosed with post-traumatic stress disorder without complete remission of symptoms, over 18 years, and who maintained pharmacological treatment. Treatment was given using electrodes as cathode (right dorsolateral prefrontal cortex) and anode (contralateral deltoid muscle); a current of 2 mA was used for 25 cm² area (0.08 mA/cm² current density); 30 min once a day for 10 days continuously. Patients assessed pre- and post-intervention, 30 days' and 90 days' post-intervention. Post-Traumatic Stress Disorder Checklist, Civilian version, Montreal Cognitive Assessment, and Hamilton Depression and Anxiety Rating Scale were used.

Results

One hundred forty-five subjects were screened and eight analyzed; 87.5% were female; 30.88 ± 7.74 years were of mean age. Post-intervention results: no cognitive impairment (Montreal Cognitive Assessment), 60% reduction in Hamilton Depression Rating Scale (moderate depression turns normal) (p < 0.001), 54.39% Hamilton Anxiety Rating Scale reduction (moderate-to-severe symptoms turn into mild symptoms) (p < 0.001), and 20% Post-Traumatic Stress Disorder Checklist, Civilian version scale decrease (high severity post-traumatic stress disorder symptoms turn moderate to moderately high severity) (p < 0.001). Post-traumatic stress disorder symptoms improvement was maintained 30-days post-intervention (Post-Traumatic Stress Disorder Checklist, Civilian version, p = 0.025) and improvement in symptoms of depression (Hamilton Depression Rating Scale, p = 0.006) and anxiety (Hamilton Anxiety Rating Scale, p = 0.028) in 90 days post-intervention.

Conclusion

Despite decrease over time, improvement in post-traumatic stress disorder, depression and anxiety symptoms was maintained throughout the first month after treatment. Transcranial direct current stimulation adjuvant can be an alternative treatment to refractory post-traumatic stress disorder, either as monotherapy or as treatment enhancement strategy. They can also be an option for patients who do not want or do not tolerate pharmacological management.

Is exercise/physical activity effective at reducing symptoms of post-traumatic stress disorder in adults — A systematic review

Background

Exercise has been used to manage symptoms of post-traumatic stress disorder (PTSD). The effect of exercise on PTSD outcomes has been previously explored in several studies. However, it still remains unclear what type of exercise/physical activity, intensity and duration is most effective for reducing symptoms of PTSD. A systematic review was conducted to determine which forms of exercise or physical activity have the greatest effect on PTSD outcome scores including an evaluation of exercise frequency and volume.

Methods

The following electronic databases were systematically searched from January 1980 to June 2021: MEDLINE, PsycINFO, PubMed and Web of Science. Inclusion criteria were studies investigating adults aged 18 or over, reporting the effect of exercise and physical activities on PTSD symptom outcome scores. Two reviewers independently extracted information on study characteristics, exposure and outcomes. In total of 3,217 articles were screened and 23 full text articles further assessed, with 13 RCT's included in the review, covering seven exercise/physical activity interventions. The study protocol was registered prospectively with PROSPERO (CRD42021255131).

Results

Thirteen studies from four countries involving a total of 531 patients were selected for inclusion. Individual forms of exercise/physical activity examined showed some effect on reducing PTSD symptoms but combined exercises (resistance training, aerobic, strength and yoga) administered over a 12 week period, three times a week for 30–60 min showed greater effects on PTSD symptoms.

Conclusion

The limited evidence suggests that a combined exercise intervention has the best evidence for a having a beneficial effect on PTSD symptoms.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=255131.

Paramedic-delivered teleconsultations: a grounded theory study

Objective

Progression in Anglo-American models of out-of-hospital care has resulted in the development of alternative roles for paramedics, including advanced paramedics providing teleconsultations to frontline paramedics. Traditionally provided by physicians, little is known about how paramedics perceive peer-to-peer teleconsultations. This research aimed to explore paramedic perceptions of paramedic-delivered teleconsultations.

Methods

This investigation employed a constructivist grounded theory methodology. Six focus groups were conducted with purposive and theoretical sampling and data analyzed using open coding and continual comparative analysis.

Results

33 paramedics from across British Columbia, Canada, participated in the focus groups. Seven key themes emerged during the focus groups; the perceived roles and status of paramedic specialists and physicians in healthcare, the influence of relationships and culture on clinical consultations, practicalities of out-of-hospital care and the importance of lived experience, provision of appropriate clinical advice, professional trust and respect, mentorship in out-of-hospital care and clinical governance and education requirements. This led to the development of the grounded theory paramedics increasing ownership of their profession.

Conclusion

Paramedics reported a number of areas in which paramedic-delivered teleconsultations provided benefits not seen with traditional physician-delivered teleconsultation model. Emergency health systems delivering an Anglo-American model of care should consider the possible benefits of paramedic-delivered teleconsultations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43678-021-00224-6.

Decision (not) to disclose mental health conditions or substance abuse in the work environment: a multiperspective focus group study within the military

OBJECTIVES

Many workers in high-risk occupations, such as soldiers, are exposed to stressors at work, increasing their risk of developing mental health conditions and substance abuse (MHC/SA). Disclosure can lead to both positive (eg, support) and negative (eg, discrimination) work outcomes, and therefore, both disclosure and non-disclosure can affect health, well-being and sustainable employment, making it a complex dilemma. The objective is to study barriers to and facilitators for disclosure in the military from multiple perspectives.

DESIGN

Qualitative focus groups with soldiers with and without MHC/SA and military mental health professionals. Sessions were audiotaped and transcribed verbatim. Content analysis was done using a general inductive approach.

SETTING

The study took place within the Dutch military.

PARTICIPANTS

In total, 46 people participated in 8 homogeneous focus groups, including 3 perspectives: soldiers with MHC/SA (N=20), soldiers without MHC/SA (N=10) and military mental health professionals (N=16).

RESULTS

Five barriers for disclosure were identified (fear of career consequences, fear of social rejection, lack of leadership support, lack of skills to talk about MHC/SA, masculine workplace culture) and three facilitators (anticipated positive consequences of disclosure, leadership support, work-related MHC/SA). Views of the stakeholder groups were highly congruent.

CONCLUSIONS

Almost all barriers (and facilitators) were related to fear for stigma and discrimination. This was acknowledged by all three perspectives, suggesting that stigma and discrimination are considerable barriers to sustainable employment and well-being. Supervisor knowledge, attitudes and behaviour were critical for disclosure, and supervisors thus have a key role in improving health, well-being and sustainable employment for soldiers with MHC/SA. Furthermore, adjustments could be made by the military on a policy level, to take away some of the fears that soldiers have when disclosing MHC/SA.

A systematic review: what factors predict Post-Traumatic Stress Symptoms in ambulance personnel?

Background:

Ambulance personnel are frequently exposed to traumatic accidents, which makes them a high risk for poor mental health. High rates of Post-Traumatic Stress Symptoms (PTSS) have been found within ambulance personnel samples but no review has been completed to examine the factors that may be implicated in the development of these symptoms. This literature review provides an overview of the factors that predict PTSS in ambulance personnel.

Methods:

A systematic search strategy was conducted in April 2020 across the following four databases: PsycINFO, PsycARTICLES, MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL).

Results:

Eighteen papers were included in this review, and the predictive factors examined were grouped into four categories: coping style, personal factors, environmental factors and organisational factors.

Conclusions:

An array of factors across the four categories were implicated in the development of PTSS, but these tended to be indicated in only one or two papers. Evidence was found to suggest that dysfunctional coping styles, reduced levels of some personality traits, proximity and nature of the critical incident and high levels of organisation stress can all lead to PTSS. Further research is needed to support the reliability of findings.

Social Embeddedness of Firefighters, Paramedics, Specialized Nurses, Police Officers, and Military Personnel: Systematic Review in Relation to the Risk of Traumatization

Background: Firefighters, paramedics, specialized nurses working in Intensive Care Units (ICUs), Operating Rooms (OR), and Emergency Rooms (ER), police officers and military personnel are more frequently exposed to potentially traumatic events than the general population; they are considered high-risk professionals. To reduce the risk of traumatization it is of great importance to be embedded in a social environment with supportive relationships. Methods: We performed a systematic review (based on the PRISMA-Guidelines) looking for social connections within the environment in which high-risk professionals are embedded (work, home, community), to obtain evidence on the impact of these connections on the risk of traumatization. Additionally, we aim to identify relevant supportive relationships in the professionals' environments. We identified the relevant scientific literature by searching, without time, and language restriction, five electronic bibliographic databases: MEDLINE, PsycINFO, Sociological Abstracts, CINAHL, and Web of Science. These databases were last searched in January 2019. Results: A qualitative analysis of the 89 eligible (out of 9,047 screened) studies shows that for firefighters, paramedics, and emergency nurses social connections in their work environment are predominantly supportive relationships and may protect them against traumatization. In other occupations (OR-nurses, ICU-nurses, police officers), however, social connections at work are not only a source of support but are also a source of stress. For military personnel study results are inconclusive as to whether their social connections at work or at home support them against traumatization. In so far as connections are supportive, their sources vary greatly from one occupational group to another; they differ between work vs. home as well as within work between peers vs. supervisor. Conclusions: Being embedded in a social environment, i.e., having social connections, is important but not always sufficient to protect high-risk professionals against traumatization. For, while these connections may be the antecedents of supportive relationships, they can also be the antecedents of damaging relationships. Additionally, the sources of supportive relationships differ among groups. This suggests that knowledge of how the social structures of the occupational groups differ may increase our understanding of the impact of social connections and relationships, including socialization, on the risk of traumatization of high-risk professionals.

Barriers and facilitators for treatment-seeking for mental health conditions and substance misuse: multi-perspective focus group study within the military

BACKGROUND

Globally, millions are exposed to stressors at work that increase their vulnerability to develop mental health conditions and substance misuse (such as soldiers, policemen, doctors). However, these types of professionals especially are expected to be strong and healthy, and this contrast may worsen their treatment gap. Although the treatment gap in the military has been studied before, perspectives of different stakeholders involved have largely been ignored, even though they play an important role.

AIMS

To study the barriers and facilitators for treatment-seeking in the military, from three different perspectives.

METHOD

In total, 46 people participated, divided into eight homogeneous focus groups, including three perspectives: soldiers with mental health conditions and substance misuse (n = 20), soldiers without mental health conditions and substance misuse (n = 10) and mental health professionals (n = 16). Sessions were audio-taped and transcribed verbatim. Content analysis was done by applying a general inductive approach using ATLAS.ti-8.4.4 software.

RESULTS

Five barriers for treatment-seeking were identified: fear of negative career consequences, fear of social rejection, confidentiality concerns, the 'strong worker' workplace culture and practical barriers. Three facilitators were identified: social support, accessibility and knowledge, and healthcare within the military. The views of the different stakeholder groups were highly congruent.

CONCLUSIONS

Barriers for treatment-seeking were mostly stigma related (fear of career consequences, fear of social rejection and the 'strong worker' workplace culture) and this was widely recognised by all groups. Social support from family, peers, supervisors and professionals were identified as important facilitators. A decrease in the treatment gap for mental health conditions and substance misuse is needed and these findings provide direction for future research and destigmatising interventions.

"Why do you stay?": The lived-experience of partners of Australian veterans and first responders with Posttraumatic Stress Disorder

This study examined the multidimensional nature of experiences of being an intimate partner of an Australian veteran or emergency service first responder (ESFR) with posttraumatic stress disorder (PTSD). Using a qualitative phenomenological approach, inductive thematic analysis was undertaken on data collected in 2017-2018 through individual interviews with a purposive sample of 22 partners of veterans, paramedics, fire and police officers living in Australia. Analysis revealed that the key concern of the participants was to protect their family unit and the intimate relationship, highlighting the ways in which they adapted, managed and coped with the changes that PTSD brought to the relationship. However, lack of understanding by healthcare providers, government, military and emergency service organizations of their daily lives, and of the strength of commitment to their relationship, resulted in a sense of invisibility and was revealed as the key barrier to the support they crave. The findings underscore the importance of recognizing the significance of the intimate relationship in trauma recovery and of responding to the support needs of the intimate partner.

High Rates of Mental Health Disorders in Civilian Employees Working in Police Organizations

Working in a police organization often involves being exposed to potentially traumatic events and stressful circumstances regardless of occupation or rank. Police mental health is a public health concern, but the mental health of civilian employees working in police organizations has been much less studied. The current study aims to compare the frequency of mental health conditions in both police officers and civilians. This was evaluated by measuring mean scores on several mental health screening tools including scales to determine symptom severity for posttraumatic stress disorder (PTSD) with the PTSD Checklist - PCL-5, depression with the Patient Health Questionnaire-9 (PHQ), general anxiety with the Generalized Anxiety Disorder 7-item scale (GAD-7), and alcohol use with the Alcohol Use Disorders Identification Test (AUDIT). The total potential population was 1,225 civilian employees and 3,714 police officers, of which 513 (10%) participated. Of these, 201 (16%) were civilians, and 312 (8%) were police officers (p<0.001). In the study population, 26% screened positive for any mental health disorder. Somewhat surprisingly, we found significantly more civilians (32.8%) than police officers (22.7%) met diagnostic criteria. We also found that civilian participants had higher mean scores in measures of PTSD, anxiety, and depression, although only for depression did this reach statistical significance. Civilians were 1.7 times more likely to screen positive for depression compared to police officers, a statistically significant difference. In contrast, police officers demonstrated statistically higher scores for alcohol use than civilians. One limitation of this study is that the data reflects responses from only a minority of the overall population and, therefore, may not accurately reflect the frequency of mental health issues in the total police organization including civilian employees. Nonetheless, the results strongly suggest that the mental health of all employees can be negatively impacted by working in a police environment, and this is important given the growing number of civilians employed within police organizations. These findings support initiatives aimed at destigmatizing mental health disorders, improving stress management, and increasing access to mental health care on an organization-wide basis, and not just limited to front-line police officers.

The impact of military service on health and well-being

Background

While it is known that some UK Armed Forces (UK AF) personnel and veterans experience physical and mental health problems, the possible future healthcare needs of military veterans are unknown.

Aims

To estimate the number of military personnel who may experience physical and/or psychological health problems associated with their military service.

Methods

Data were obtained via Freedom of Information requests to several sources, including Defence Statistics. Raw data from research studies were also used where available. Data were analysed using meta-analytic methods to determine the rate of physical, mental or comorbid health problems in AF personnel.

Results

Musculoskeletal problems were the predominant reason for medical discharge from service. In terms of mental health, meta-analyses estimated that veteran reservists (part-time military members) previously deployed to operational areas had the highest proportion of general health problems (35%), previously deployed veteran regulars (those in full time military employment) and veteran reservists had the highest proportion of post-traumatic stress disorder (9%), and regular personnel with a deployment history had the highest proportion of alcohol problems (14%). Overall, our findings suggest that at least 67515 veterans are likely to suffer from mental and/or physical health problems at some point as a result of their service between 2001 and 2014.

Conclusions

The results of this study highlight that the difficulties personnel may face are largely musculoskeletal or mental health-related. These findings may help with planning the provision of future physical and mental health care and support for those who serve in the UK AF.

Inflammation in Post-Traumatic Stress Disorder (PTSD): A Review of Potential Correlates of PTSD with a Neurological Perspective

Post-traumatic stress disorder (PTSD) is a chronic condition characterized by symptoms of physiological and psychosocial burden. While growing research demonstrated signs of inflammation in PTSD, specific biomarkers that may be representative of PTSD such as the detailed neural correlates underlying the inflammatory responses in relation to trauma exposure are seldom discussed. Here, we review recent studies that explored alterations in key inflammatory markers in PTSD, as well as neuroimaging-based studies that further investigated signs of inflammation within the brain in PTSD, as to provide a comprehensive summary of recent literature with a neurological perspective. A search was conducted on studies published from 2009 through 2019 in PubMed and Web of Science. Fifty original articles were selected. Major findings included elevated levels of serum proinflammatory cytokines in individuals with PTSD across various trauma types, as compared with those without PTSD. Furthermore, neuroimaging-based studies demonstrated that altered inflammatory markers are associated with structural and functional alterations in brain regions that are responsible for the regulation of stress and emotion, including the amygdala, hippocampus, and frontal cortex. Future studies that utilize both central and peripheral inflammatory markers are warranted to elucidate the underlying neurological pathway of the pathophysiology of PTSD.

Posttraumatic stress disorder symptoms and sleep in the daily lives of World Trade Center responders

Sleep disturbances are common in posttraumatic stress disorder (PTSD) and can have major impacts on workplace performance and functioning. Although effects between PTSD and sleep broadly have been documented, little work has tested their day-to-day temporal relationship particularly in those exposed to occupational trauma. The present study examined daily, bidirectional associations between PTSD symptoms and self-reported sleep duration and quality in World Trade Center (WTC) responders oversampled for PTSD. WTC responders (N = 202; 19.3% with current PTSD diagnosis) were recruited from the Long Island site of the WTC health program. Participants were administered the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; SCID; First, Spitzer, Gibbon, & Williams, 1997) and completed daily assessments of PTSD symptoms, sleep duration and sleep quality for 7 days. PTSD symptoms on a given day were prospectively associated with shorter sleep duration (β = -.13) and worse sleep quality (β = -.18) later that night. Reverse effects were also significant but smaller, with reduced sleep duration (not quality) predicting increased PTSD the next day (β = -.04). Effects of PTSD on sleep duration and quality were driven by numbing symptoms, whereas effects of sleep duration on PTSD were largely based on intrusion symptoms. PTSD symptoms and sleep have bidirectional associations that occur on a daily basis, representing potential targets to disrupt maintenance of each. Improving PTSD numbing symptoms may improve sleep, and increasing sleep duration may improve intrusion symptoms in individuals with exposure to work-related traumatic events. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

"I've had to bury a lot of kids over the years…": Violence prevention streetworkers' exposure to trauma

AIMS

Streetworkers are front-line workers employed to engage at-risk youth and prevent, intervene, and respond to incidents of community youth violence. Streetworkers are often exposed to violence and its aftermath, though little is known about the specific types of trauma to which streetworkers are exposed.

METHODS

This study seeks to explore this question via in-depth, semistructured interviews with 37 streetworkers from a large city in the United States.

RESULTS

The qualitative results revealed that the streetworkers in this sample experienced a range of types of trauma. Streetworkers were less likely to be directly exposed to traumatic events in the context of their jobs, yet were more likely to witness, learn about, or experience repeated exposure to aversive details of traumatic events.

CONCLUSIONS

Despite their exposure to trauma, very few participants described seeking psychological treatment, self-care, or new vocation. We discuss our findings and make recommendations to bolster support for streetworkers.

Burnout and Exposure to Critical Incidents in a Cohort of Emergency Medical Services Workers from Minnesota

Introduction

Very little quantitative data on occupational burnout and exposure to critical incidents are available from contemporary United States emergency medical services (EMS) cohorts. Given that burnout has been associated positively with turnover intentions and absenteeism in EMS workers, studies that uncover correlates of burnout may be integral to combating growing concerns around retention in the profession.

Methods

We administered a 167-item electronic survey that included the Maslach Burnout Inventory (MBI) and a modified version of the Critical Incident History Questionnaire (n=29 incident types) to paramedics, emergency medical technicians (EMTs), and dispatchers of a single ambulance service. We defined the presence of burnout as a high score on either the emotional exhaustion or depersonalization subscales of the MBI.

Results

Survey respondents who provided regular 911 response at the time of the survey and completed the MBI portion of the survey were included in our analysis (190 paramedics/EMTs, 19 dispatchers; 54% response). The overall prevalence of burnout was 18%, with prevalence reaching 32% among dispatchers. The seven pediatric critical incident types presented in the survey accounted for seven of the top eight rated most difficult to cope with, and severity ratings for pediatric critical incidents did not differ by parental status (all p>0.30). A significant number of respondents reported that they had been threatened with a gun/weapon (43%) or assaulted by a patient (68%) at least once while on duty. Being over the age of 50, a parent, or in a committed relationship was associated with reduced odds of burnout in unadjusted models; however, these associations did not remain statistically significant in multivariate analysis. Increasing tertile of career exposure to critical incidents was not associated with burnout.

Conclusion

Medical dispatchers may be an EMS subgroup particularly susceptible to burnout. These data also demonstrate quantitatively that in this EMS agency, responders find pediatric critical incidents especially distressing and that violence against responders is commonplace. In this study, a simple measure of career exposure to potentially critical incidents was not associated with burnout; however, individual reactions to incidents are heterogeneous, and assessment tools that more accurately enumerate encounters that result in distress are needed.

On-Duty Nonfatal Injury that Lead to Work Absences Among Police Officers and Level of Perceived Stress

OBJECTIVE

We examined prevalence, frequency, duration, and recency of injury leave and the association of duty-related injury with perceived stress in U.S. police officers.

METHODS

This cross-sectional study contained 422 active duty police officers from a mid-sized urban police department. For each participating officer, work history records were used to assess on-duty injuries that lead to work absences. Linear regression analyses were used for analyses.

RESULTS

Most participants had experienced at least one injury (62%), and among those injured, 67% experienced more than one duty-related injury. The average number of injuries per officer was three (range 1 to 12). There was a significant linear trend in mean perceived stress across injury count even after adjusting for age, rank, and sex (P = 0.025).

CONCLUSION

Findings suggest that work-related injury is common and repeated work-related injuries are psychologically distressing in U.S. police officers.

Research into Australian emergency services personnel mental health and wellbeing: An evidence map

BACKGROUND

Evidence maps are a method of systematically characterising the range of research activity in broad topic areas and are a tool for guiding research priorities.

AIMS

'Evidence-mapping' methodology was used to quantify the nature and distribution of recent peer-reviewed research into the mental health and wellbeing of Australian emergency services personnel.

METHODS

A search of the PsycINFO, EMBASE and Cochrane Library databases was performed for primary research articles that were published between January 2011 and July 2016.

RESULTS

In all, 43 studies of primary research were identified and mapped. The majority of the research focused on organisational and individual/social factors and how they relate to mental health problems/wellbeing. There were several areas of research where very few studies were detected through the mapping process, including suicide, personality, stigma and pre-employment factors that may contribute to mental health outcomes and the use of e-health. No studies were detected which examined the prevalence of self-harm and/or harm to others, bullying, alcohol/substance use, barriers to care or experience of families of emergency services personnel. In addition, there was no comprehensive national study that had investigated all sectors of emergency services personnel.

CONCLUSION

This evidence map highlights the need for future research to address the current gaps in mental health and wellbeing research among Australian emergency services personnel. Improved understanding of the mental health and wellbeing of emergency services personnel, and the factors that contribute, should guide organisations' wellbeing policies and procedures.

The relationship between trauma centrality, self-efficacy, posttraumatic stress and psychiatric co-morbidity among Syrian refugees: Is gender a moderator?

This study examined the inter-relationship between trauma centrality, self-efficacy, posttraumatic stress disorder (PTSD) and psychiatric co-morbidity among a group of Syrian refugees living in Turkey, and whether gender would moderate the mediational effect of self-efficacy on the impact of trauma centrality on distress. Seven hundred and ninety-two Syrian refugees completed the Harvard Trauma Questionnaire, General Health Questionnaire-28, Centrality of Event Scale and Generalized Self-Efficacy Scale. The results showed that 52% met the cutoff for PTSD. Trauma centrality was positively correlated with PTSD, psychiatric co-morbidity and self-efficacy. Self-efficacy was negatively correlated with PTSD only. Gender did not moderate the mediational effect of self-efficacy on the path between trauma centrality and distress outcomes. To conclude, following exposure to traumatic events, more than half reported PTSD. Perception of the future and identity construction was affected. Signs of psychological distress were evident, alongside resilience, regardless of gender.

Trauma exposure relates to heightened stress, altered amygdala morphology and deficient extinction learning: Implications for psychopathology

Stress exposure causes a structural reorganization in neurons of the amygdala. In particular, animal models have repeatedly shown that both acute and chronic stress induce neuronal hypertrophy and volumetric increase in the lateral and basolateral nuclei of amygdala. These effects are visible on the behavioral level, where stress enhances anxiety behaviors and provokes greater fear learning. We assessed stress and anxiety levels in a group of 18 healthy human trauma-exposed individuals (TR group) compared to 18 non-exposed matched controls (HC group), and related these measurements to amygdala volume. Traumas included unexpected adverse experiences such as vehicle accidents or sudden loss of a loved one. As a measure of aversive learning, we implemented a cued fear conditioning paradigm. Additionally, to provide a biological marker of chronic stress, we measured the sensitivity of the hypothalamus-pituitary-adrenal (HPA) axis using a dexamethasone suppression test. Compared to the HC, the TR group showed significantly higher levels of chronic stress, current stress and trait anxiety, as well as increased volume of the left amygdala. Specifically, we observed a focal enlargement in its lateral portion, in line with previous animal data. Compared to HC, the TR group also showed enhanced late acquisition of conditioned fear and deficient extinction learning, as well as salivary cortisol hypo-suppression to dexamethasone. Left amygdala volumes positively correlated with suppressed morning salivary cortisol. Our results indicate differences in trauma-exposed individuals which resemble those previously reported in animals exposed to stress and in patients with post-traumatic stress disorder and depression. These data provide new insights into the mechanisms through which traumatic stress might prompt vulnerability for psychopathology.

PTSD in Court I: Introducing PTSD for Court

The first part of the series of three articles on posttraumatic stress disorder (PTSD) in Court to appear in the journal reviews the history of the construct of PTSD and its presentation in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; American Psychiatric Association, 2013) and the ICD-11 (International Classification of Diseases, 11th Edition; World Health Organization, 2018). There are 20 symptoms of PTSD in the DSM-5. PTSD symptoms are arranged into a four-cluster model, which has received partial support in the literature. Other four-factor models have been found that fit the data even better than that of the DSM-5. There is a five-factor dysphoria model and two six-factor models that have been found to fit better the DSM-5 PTSD symptoms. Finally, research is providing support for a hybrid seven-factor model. An eighth factor on dissociation seems applicable to the minority of people who express the dissociative subtype. At the epidemiological level, individuals can expect trauma exposure to take place about 70% over one's lifetime. Also, traumatic exposure leads to traumatic reactions in about 10% of cases, with PTSD being a primary diagnosis for trauma. Once initiated, PTSD becomes prolonged in about 10% of cases. Polytrauma and comorbidities complicate these prevalence statistics. Moreover, the possibility of malingered PTSD presents confounds. However, the estimate for malingered PTSD varies extensively, from 1 to 50%, so that the estimate is too imprecise for use in court without further research. This first article in the series of three articles appearing in the journal on PTSD in Court concludes with discussion of complications related to comorbidities and heterogeneities, in particular. For example, PTSD and its comorbidities can be expressed in over one quintillion ways. This complexity in its current structure in the DSM-5 speaks to the individual differences involved in its expression.

What Occupational Health Needs Arise in Workplaces Following Disasters? A Joint Analysis of Eight Cases of Disaster in Japan

OBJECTIVE

To identify occupational health needs arising after disasters.

METHODS

Using semistructured interviews with expert informants, we jointly analyzed the needs arising in eight disaster cases that threatened the lives or health of workers in Japan.

RESULTS

Various types of health issues occurred in a wide range of employees. In total, we identified 100 needs in six phases after disasters and classified them across nine categories of worker characteristics. The proportion of health needs on the list that were applicable in each case varied from 13% to 49%. More needs arose when the companies were responsible for the disaster and when employee lives were lost. We also assessed the list as fairly comprehensive.

CONCLUSIONS

The list developed in this study is expected to be effective for anticipating occupational health needs after disasters.

Assessing postdisaster psychological stress in hazardous waste operations and emergency response (HAZWOPER) workers

OBJECTIVE

To assess the prevalence of traumatic stress experienced by secondary responders to disaster events to determine if mental health education should be included in HAZWOPER training.

METHODS

Preexisting survey tools for assessing posttraumatic stress disorder (PTSD), resiliency, and mental distress were combined to form a web-based survey tool that was distributed to individuals functioning in secondary response roles. Data were analyzed using the Fisher exact test, 1-way ANOVA, and 1-sample t tests.

RESULTS

Respondents reported elevated PTSD levels (32.9%) as compared to the general population. HAZWOPER-trained responders with disaster work experience were more likely to be classified as PTSD positive as compared to untrained, inexperienced responders and those possessing only training or experience. A majority (68.75%) scored below the mean resiliency level of 80.4 on the Connor-Davidson Resilience Scale. Respondents with only training or both training and experience were more likely to exhibit lower resiliency scores than those with no training or experience. PTSD positivity correlated with disaster experience. Among respondents, 91% indicated support for mental health education.

CONCLUSIONS

Given the results of the survey, consideration should be given to the inclusion of pre- and postdeployment mental health education in the HAZWOPER training regimen.

Verlaufsuntersuchung depressiver Symptomatik nach akuter Traumatisierung

Hintergrund: Der Zusammenhang zwischen Akuter Belastungsstörung (ASD) und der Posttraumatischen Belastungsstörung (PTSD) ist vielfach untersucht. Wenige Erkenntnisse liegen über den klinischen Verlauf depressiver Symptome nach ASD vor. Fragestellung: Unterscheiden sich Patienten nach akuter Traumatisierung hinsichtlich der Entwicklung depressiver Symptome von Nicht-Traumatisierten? Methode: 39 akut Traumatisierte wurden mit einer gesunden Kontrollgruppe (KG, N=38) verglichen. Die ASD und die depressiven Symptome wurden mit standardisierten Verfahren (SKID, ASDS, DS) zu verschiedenen Messzeitpunkten untersucht. Ergebnisse: ASD-Patienten waren initial signifikant depressiver als die KG. Nach anfänglicher Beschwerderemission nahmen die depressiven Symptome bei der Gruppe der späteren PTSD-Patienten wieder zu. Schlussfolgerung: Depressive Symptome nach ASD sind sowohl bei Patienten mit als auch ohne nachfolgende PTSD häufig. Nach anfänglicher Remission der depressiven Beschwerden kann es zu einer Reexazerbation kommen.

Targeting memory processes with drugs to prevent or cure PTSD

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a chronic debilitating psychiatric disorder resulting from exposure to a severe traumatic stressor and an area of great unmet medical need. Advances in pharmacological treatments beyond the currently approved SSRIs are needed.

AREAS COVERED

Background on PTSD, as well as the neurobiology of stress responding and fear conditioning, is provided. Clinical and preclinical data for investigational agents with diverse pharmacological mechanisms are summarized.

EXPERT OPINION

Advances in the understanding of stress biology and mechanisms of fear conditioning plasticity provide a rationale for treatment approaches that may reduce hyperarousal and dysfunctional aversive memories in PTSD. One challenge is to determine if these components are independent or reflect a common underlying neurobiological alteration. Numerous agents reviewed have potential for reducing PTSD core symptoms or targeted symptoms in chronic PTSD. Promising early data support drug approaches that seek to disrupt dysfunctional aversive memories by interfering with consolidation soon after trauma exposure, or in chronic PTSD, by blocking reconsolidation and/or enhancing extinction. Challenges remain for achieving selectivity when attempting to alter aversive memories. Targeting the underlying traumatic memory with a combination of pharmacological therapies applied with appropriate chronicity, and in combination with psychotherapy, is expected to substantially improve PTSD treatment.

Posttraumatic stress disorder among paramedics: exploring a new solution with occupational health nurses using the Ottawa Charter as a framework

Paramedics have the highest rate of posttraumatic stress disorder (PTSD) among emergency service workers, higher than police or firefighters. This disorder can be detrimental to their personal and family lives, as well as their careers. Current biomedical, behavioral, and socioenvironmental interventions do not address paramedics' work environment, which contributes to the high rate of PTSD. Occupational health nurses can influence the triad of factors contributing to PTSD among paramedics by facilitating social support and emotional expression while advocating for reduced job exposure to traumatic events. This goal can be accomplished by using a component of the Ottawa Charter, creating a supportive work environment, as a framework. Occupational health nurses, together with management and paramedics, can facilitate a sustainable and supportive work environment that initiates change from within the trauma membrane of paramedics' workplaces to prevent PTSD.

Work-Related Predictors of Psychological Distress among Medical Examiner and Coroner Personnel

Personnel employed in medical examiner and coroner offices are involved in the identification of the deceased, the determination of causes of death, and the communication of this information to relevant parties, including the families of the victims, public health authorities and the criminal justice system. Although the mental health needs of other types of emergency workers (i.e., fire, police, emergency medical services) have been well identified and acknowledged in the literature and in planning efforts, the mental health needs of medical examiner and coroner personnel have not received the same attention. The aim of this study was to identify predictors of mental and physical health symptoms among employees of medical examiner and coroner offices. Data was collected from a convenience sample composed of employees of eight medical examiner sites nationwide, attendees of a coroners' conference, and through the web. A total of 395 employees completed a survey evaluating symptoms of depression, posttraumatic stress, anxiety, self-reported health and sleep quality. Results indicated variations among job titles in the intensity of mental and physical health symptoms, with investigators, clerical and administrative staff, and coroners reporting the highest levels of symptoms. Work-related stressors associated with increased levels of psychological symptoms included: exposure to cases involving the accidental death of infants, as well as stress associated with interacting with the families of the deceased and concerns about bringing home infection or illness. The results have implications for the development of intervention strategies designed to prevent work-related illness in medical examiner personnel.

Impact of traumatic loss on post-traumatic spectrum symptoms in high school students after the L'Aquila 2009 earthquake in Italy

BACKGROUND

On April 6th 2009, the town of L'Aquila, Italy, was struck by an earthquake (6.3 on the Richter scale) that lead large parts of the town to be destroyed and the death of 309 people. Significant losses in the framework of earthquakes have been reported as a major risk factor for PTSD development. Aim of this study was to investigate post-traumatic spectrum symptoms in a sample of adolescents exposed to the L'Aquila 2009 earthquake 21 months earlier, with particular attention to the impact of loss.

METHODS

475 students (203 women and 272 men), attending the last year of High School in L'Aquila, were assessed by: Trauma and Loss Spectrum-Self Report (TALS-SR) and Impact of Event Scale (IES). The presence of full and partial PTSD was also assessed.

RESULTS

72 students (15.2%) reported the loss of a close friend or relative in the framework of the earthquake. Full PTSD was reported by 146 (30.7%) students and partial PTSD by 149 (31.4%) students. There was a significant difference reported in PTSD between bereaved and non bereaved subjects. Significantly higher post-traumatic symptom levels were reported by bereaved subjects.

LIMITATIONS

The lack of information on the relationship with the deceased and the number of losses experienced, besides the use of self report instruments are the limitations of this study.

CONCLUSIONS

Our results show high rates of post-traumatic spectrum symptoms in adolescents who survived the L'Aquila earthquake. Having experienced the loss of a close friend or a relative in the framework of the earthquake seems to be related to higher PTSD rates and more severe symptomatology. These results highlight the need to carefully explore adolescents exposed to a significant loss as consequence of an earthquake.

The longitudinal course of PTSD among disaster workers deployed to the World Trade Center following the attacks of September 11th

This study examined the long-term mental health outcomes of 2,960 nonrescue disaster workers deployed to the World Trade Center site in New York City following the September 11, 2001 (9/11) terrorist attacks. Semistructured interviews and standardized self-report measures were used to assess the prevalence of posttraumatic stress disorder (PTSD) and other psychopathology 4 and 6 years after the attacks. Clinician-measured rates of PTSD and partial PTSD 4-years posttrauma were 8.4% and 8.9%, respectively, in a subsample of 727 individuals. Rates decreased to 5.8% and 7.7% for full and partial PTSD 6 years posttrauma. For the larger sample, self-report scores revealed probable PTSD and partial PTSD prevalence to be 4.8% and 3.6% at 4 years, and 2.4% and 1.8% at 6 years. Approximately 70% of workers never met criteria for PTSD. Although PTSD rates decreased significantly over time, many workers remained symptomatic, with others showing delayed-onset PTSD. The strongest predictors of ongoing PTSD 6 years following 9/11 were trauma history (odds ratio (OR) = 2.27, 95% confidence interval (CI) [1.06, 4.85]); the presence of major depressive disorder 1-2 years following the trauma (OR = 2.80, 95% CI [1.17, 6.71]); and extent of occupational exposure (OR = 1.31, 95% CI [1.13, 1.51]). The implications of the findings for both screening and treatment of disaster workers are discussed.