Is Cumulative Exposure to Suicide Attempts and Deaths a Risk Factor for Suicidal Behavior Among Firefighters? A Preliminary Study

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.

Suicides among American Indian/Alaska Native firefighters: Data from the National Violent Death Reporting System, 2003 - 2017

Suicide is a significant public health problem in the United States and disproportionally affects male American Indian/Alaska Natives (AI/AN). Suicide is particularly problematic among AI/AN firefighters who are more likely to report suicide ideation, planning, attempts, and risk compared to non-Hispanic white (NHW) firefighters. The aim of the current study was to compare non-Hispanic AI/AN firefighter and NHW firefighter suicide decedents by demographics and risk/precipitating factors using National Violent Death Reporting System data for 45 male non-Hispanic AI/AN firefighter and 588 male NHW firefighter decedents who died by suicide. Compared to NHW firefighter decedents, AI/AN firefighter decedents were significantly younger and had significantly higher odds of experiencing alcohol use problems and a recent death/suicide of a family member/friend. AI/AN firefighter decedents had significantly lower odds of documented mental health problems, documented diagnosis of depression/dysthymia, receipt of mental health treatment, or leaving a suicide note compared to NHW firefighter decedents. Results from this study may inform tailored suicide prevention and screening efforts among first responders with the goal of lowering suicide mortality among AI/AN firefighters and fire service as a whole.

Stamp Out Stigma: a national campaign to decrease stigma and increase behavioral health in fire service

Firefighters are at risk for behavioral health problems; however, mental health stigma is a barrier to seeking treatment. Although effective treatments exist, many firefighters report that internal stigma prohibits presentation for effective care. This study aimed to decrease stigma about behavioral health in fire service through the development and delivery of a peer-led anti-stigma intervention campaign called Stamp Out Stigma (SOS). SOS consisted of three related phases. During Phase 1 (n = 12), we produced testimonials and piloted the videos with firefighters to determine which were most compelling. During Phase 2 (n = 23), we beta-tested our training curriculum with two departments, resulting in a significant decrease in internalized stigma but not in self-stigma. During Phase 3 (n = 73), we presented the curriculum to two cohorts of firefighters. Participation in the SOS workshop was associated with a significant decrease in firefighters' self-stigma from pre-, M = 22.7, SD = 6.3, to post-workshop, M = 20.8, SD = 5.5, t(66) = 3.2, p = 0.002. Participation in the SOS workshop was associated with a significant decrease in firefighters' internalized stigma, M = 2.0, SD = 0.5, to post-workshop, M = 1.8, SD = 0.4, t(66) = 2.8, p = 0.007. The SOS approach to stigma reduction is promising for modifying negative attitudes toward mental health and treatment seeking among professional firefighters.

Suicide among emergency service workers: a retrospective mortality study of national coronial data, 2001-2017

BACKGROUND

Emergency service workers (ESW) are known to be at increased risk of mental disorders but population-level and longitudinal data regarding their risk of suicide are lacking.

METHOD

Suicide data for 2001-2017 were extracted from the Australian National Coronial Information Service (NCIS) for two occupational groups: ESW (ambulance personnel, fire-fighters and emergency workers, police officers) and individuals employed in all other occupations. Age-standardised suicide rates were calculated and risk of suicide compared using negative binomial regression modelling.

RESULTS

13 800 suicide cases were identified among employed adults (20-69 years) over the study period. The age-standardised suicide rate across all ESW was 14.3 per 100 000 (95% CI 11.0-17.7) compared to 9.8 per 100 000 (95% CI 9.6-9.9) for other occupations. Significant occupational differences in the method of suicide were identified (p < 0.001). There was no evidence for increased risk of suicide among ESW compared to other occupations once age, gender and year of death were accounted for (RR = 0.99, 95% CI 0.84-1.17; p = 0.95). In contrast, there was a trend for ambulance personnel to be at elevated risk of suicide (RR = 1.41, 95% CI 1.00-2.00, p = 0.053).

CONCLUSION

Whilst age-standardised suicide rates among ESW are higher than other occupations, emergency service work was not independently associated with an increased risk of suicide, with the exception of an observed trend in ambulance personnel. Despite an increased focus on ESW mental health and wellbeing over the last two decades, there was no evidence that rates of suicide among ESW are changing over time.

Unpacking the Meaning of Closeness, Reconsidering the Concept of Impact in Suicide Exposure, and Expanding Beyond Bereavement: "Just, I Hope You Don't Forget About Us"

Suicide exposure research has relied on samples of treatment-seeking kin, resulting in an attachment-based model centering bereavement as the most significant form of impact and obscuring other forms of significant and life-altering impact. From a community-based sample (N = 3010) exposed to suicide, we examine a subset (n = 104) with perceived high impact from the death yet low reported closeness to the person who died and analyze qualitative comments (n = 50). On average and out of 5.00, participants rated closeness as 1.56 but impact of death as 4.51. We illustrate dimensions of low closeness and identify themes on the meaning of impact: impact through society and systemic circumstances, impact through history and repeated exposure, impact through other people, impact as a motivator for reflection or change, and impact through shared resonance. Participants reported impact of death as significant or devastating, yet none of their comments reflected experiences typical of bereavement.

Web-Based Mind-Body Tactical Resilience Training Program for First Responders: Pre-Post Study Assessing Feasibility, Acceptability, and Usability

BACKGROUND

First responders report elevated rates of mental disorders, including posttraumatic stress disorder (PTSD), yet many are reluctant to seek care. Preventative resilience training programs attempt to proactively address this issue, and there is evidence showing promise for programs targeting cognitive processes. However, these programs rarely address the physical health conditions associated with PTSD. There is emerging evidence of mind-body exercise training improving PTSD symptoms as well as its associated physical health symptoms. However, the feasibility and acceptability of delivering a web-based mind-body resilience training among first responders are not yet known.

OBJECTIVE

This study aimed to evaluate the feasibility, usability, and acceptability of a web-based mind-body tactical resilience training program designed for first responders. In addition, we explored the preliminary effectiveness of the training program on mental health outcomes, adaptive cognitive strategies, and work productivity.

METHODS

A total of 42 first responders based in the United States enrolled in the web-based training program. Participants were administered web-based surveys before enrolling in the 6-week web-based program and at the end of the program. The primary outcomes of feasibility were measured using the number of training hours, program adherence rates, and self-reported data on frequency of practice. Acceptability and usability were measured using self-reported data. Secondary outcomes were symptoms of PTSD, psychological distress, emotion regulation, stress mindset, psychological preparedness, and work performance.

RESULTS

Overall, the training program was feasible based on the median number of training hours spent on the web-based program (7.57 hours out of an expected total of 6 to 9 hours), and 55% (23/42) of the enrolled participants completed more than half of the program. Although acceptability, usability, and frequency of practice were rated as high, this was based on only 29% (12/42) of the respondents who provided follow-up data. Secondary outcomes showed a significant improvement in the adaptive cognitive strategy of the stress mindset, with a mean difference of -5.42 (SD 4.81; 95% CI -8.475 to -2.358; t₁₁=-3.898; P=.002). All other secondary outcomes were not significant. However, the secondary outcomes were exploratory only, and this study was neither designed nor powered to adequately assess efficacy.

CONCLUSIONS

These findings suggest that a mind-body tactical resilience training program delivered in a web-based format is feasible and acceptable among first responders; however, further refinements may be required to improve adherence rates. Further research using a larger, more rigorous trial design is warranted to examine the effectiveness of this type of training as a possible prevention or treatment strategy for this population.

Towards an Evidence-Based Model of Workplace Postvention

This instrumental case study explored what suicide postvention might offer workplaces using the example of a large metropolitan funeral company. A mixed methods approach was utilized to examine staff experiences with suicide bereavement funerals and responses to a bespoke postvention training package. Staff found funerals due to suicide difficult in terms of communication, engagement and emotionality. These challenges were commonly characterized by increased tension and concern. In the absence of a postvention informed approach, staff had developed individual ways to negotiate the identified challenges of this work. The introduction of a staff-informed postvention training package delivered improvements in staff confidence with communication, understanding and management of the impact of suicide bereavement, and increased willingness to share information about postvention services with families and mourners. The findings indicated that benefits of the training could be extended through organizational governance and integration of supports. The findings are used to inform a model of workplace postvention together with a methodology incorporating staff experience and organizational context.

Suicide exposure experience screener for use in therapeutic settings: A validation report

INTRODUCTION

A brief screener assessing experience of exposure to suicide for use in therapeutic settings is warranted. To examine the concurrent validity of such a screening tool, labeled as the Suicide Exposure Experience Screener (SEES), the associations of the two SEES items: (i) reported closeness with the person who died by suicide and (ii) perceived impact of suicide death with psychological distress are presented.

METHODS

Five separate datasets comprising surveys from Australia, Canada, and the United States (N_combined  = 7782) were used to provide evidence of concurrent validity of closeness and impact of suicide exposure.

RESULTS

Overall, closeness and impact were significantly correlated with measures of global distress across five different datasets, showing small to medium effect sizes. Closeness and impact were also intercorrelated demonstrating a large effect size across all surveys. This report used cross-sectional data and comprised varied sample sizes across different datasets that influenced statistical significance of obtained effects and did not tease apart the roles of cumulative exposure of suicide and prolonged bereavement in experiencing global distress.

CONCLUSION

The SEES has clinical utility in determining psychological distress in bereaved individuals and is recommended for use in therapeutic settings.

Understanding Capability and Suicidal Ideation among First Responders

OBJECTIVE

The present study seeks to determine differences in lifetime suicidal ideation, dispositional capability, acquired capability, and practical capability among those who have and have not served as first responders, and among subgroups of first responders.

METHODS

Data were collected as part of a large online (n = 3,500) study seeking to understand firearm ownership in the United States. Participants were recruited via Qualtrics Panels and were demographically matched to the 2010 US census. Binary logistic regressions and an exploratory multinomial logistic regression examined differences between first responders and non-first responders and among subgroups of first responders.

RESULTS

First responders reported more lifetime suicidal ideation and higher acquired, practical, and dispositional capability than did non-first responders. Findings indicated that first responders with and without military affiliation did not differ in terms of suicidal ideation or capability for suicide. Lastly, law enforcement officers (LEOs) reported more lifetime suicidal ideation than emergency medical technicians (EMTs). LEOs, EMTs, and firefighters did not differ in terms of capability for suicide.

DISCUSSION

The findings highlight that suicidal ideation and capability for suicide differ between first responders and non-first responders and among subgroups of first responders. The mechanisms driving the increased rates of suicidal ideation and capability among first responders are unknown; however, it is likely due to a combination of personal and occupational factors. Although not without its limitations, the present study provides an understanding of suicide risk among first responders.

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.

Workplace Mental Health Awareness Training: A Cluster Randomized Controlled Trial

OBJECTIVE

To investigate the efficacy of a workplace mental health awareness training program on help-seeking and mental health outcomes.

METHODS

A cluster randomized controlled trial was conducted comparing those who received standard training (N = 210) or standard training with a mental health awareness module (N = 208). Both groups were followed up for 3 years with the primary outcome being likelihood to seek help.

RESULTS

Rates of likely help-seeking were slightly higher in the intervention group 6 months after the training, but this was not maintained over time. There was no significant difference between study conditions for mental health outcomes or actual help-seeking among those with probable mental disorder at any time point.

CONCLUSIONS

Workplace mental health awareness training has a limited short-term impact on likelihood of help-seeking and does not appear to improve mental health outcomes.

Bearing witness: A grounded theory of the experiences of staff at two United Kingdom Higher Education Institutions following a student death by suicide

Wider networks of people are affected by a suicide death than originally thought, including those whose job-role brings them into contact with a death by suicide of another person. The impact of student suicide within United Kingdom (UK) Higher Education Institutions (HEIs) is unexplored and the experiences of staff members remain unknown. It is not known whether staff members have specific postvention needs following a student death by suicide. Any postvention support currently offered to staff members within UK HEIs lacks a context-specific evidence base. This study asked 'How is a student suicide experienced by staff members within a UK HEI and what are the features of that experience?' Staff members from diverse job-roles in two UK HEIs responded to a qualitative survey (n = 19) and participated in semi-structured interviews (n = 10). Data were transcribed and subjected to a constructivist grounded theory analysis. Participants' experiences informed the development of a core category: 'Bearing witness', which encompassed six further categories: 'Responding to a student suicide'; 'Experiencing a student suicide'; 'Needs and fears'; 'Experiences of support'; 'Human stories'; and 'Cultural stories'. The resulting grounded theory demonstrates how participants' perceptions of impact are informed by their experiences of undertaking tasks following a student suicide within the community of their HEI. Processes of constructing perceptions of closeness to the student who died are evident amongst participants who did not know the student prior to their death. Tailored postvention support is required to respond to the range and complexity of HEI staff needs following a student death by suicide.

Occupational exposure to suicide: A review of research on the experiences of mental health professionals and first responders

Exposure to suicide is a major factor for suicidality. Mental health professionals and first responders are often exposed to suicide while on-duty. The objective of this scoping review is to describe the state of current research on exposure to suicide among mental health professionals and first responders, focusing on the prevalence and impact of exposure to suicide, and to identify current gaps in the literature. We searched MEDLINE, Scopus, PsychNET, and Web of Science and identified 25 eligible papers. Between 31.5–95.0% of professionals had been exposed to suicide. Exposure to suicide had impacts on personal life, professional life, and mental health; and caused emotional distress. There was little research investigating exposure to suicide among police officers, firefighters, and paramedics. More research existed on mental health professionals, but none assessed exposure to suicide as a risk for suicide amongst this group. The review concludes that exposure to suicide is distressing for mental health professionals, and likely to be for first responder however, more research on these groups, especially paramedics, is required.

Prevalence and predictors of suicidal thoughts and behaviours among Australian police and emergency services employees

OBJECTIVE

This study presents rates of suicide thoughts and behaviours of police and emergency services personnel around Australia. In addition, it examines personal (i.e. mental health, substance use) and working environment risk and protective factors.

METHOD

A stratified random sample of personnel from 33 Australian emergency services organisations were invited to participate in a mental health and wellbeing survey. In total, 14,868 Australian ambulance, fire and rescue, police and state emergency services employees participated and self-reported any suicidal thoughts, plans and/or attempts in the 12 months prior to the survey or at any stage in their life. Logistic regressions assessed factors associated with suicidal thoughts and behaviours.

RESULTS

Employees reported notably higher rates of suicidal thoughts and plans than the general Australian adult population, but not attempts. Male, single/divorced, non-heterosexual or longer-serving employees reported higher rates of suicidal thoughts and behaviours across each sector. Perceptions of stigma regarding mental health conditions from others in the workplace, negative impact of work on one's private life and low meaning of work were associated with suicidal thoughts, while bullying significantly differentiated who planned and attempted suicide from those who reported suicidal thoughts only. Higher resilience and social support were associated with lower suicidal thoughts, while intermittent explosive anger and illegal drug use were associated with higher rates of suicidal thoughts. Post-traumatic stress disorder symptoms significantly differentiated who planned suicide, while misuse of prescription drugs and psychological distress differentiated who attempted suicide from those who only reported suicidal thoughts.

CONCLUSION

Amid inherently stressful occupations, it is important that workplaces function in a way that supports their personnel. Access to mental health services should be promoted and readily available to personnel.

Workplace exposure to suicide among Australian mental health workers: A mixed-methods study

Workplace exposure to suicide attempts and deaths has been widely recognized as an occupational hazard for mental health and social care workers, including mental health nurses. Research consistently demonstrates the adverse impact on professionals. This paper explores the results of an online survey examining suicide exposure and impact. Of the 3010 Australian adult participants who identified exposure to suicide attempts and/or deaths in a larger study, 130 indicated that the most impactful suicide attempt and/or death exposure was that of a client or service user. While distress levels were relatively low among participants with workplace exposure, the qualitative content from 53 participants provides illumination into this experience. Themes that emerged in the qualitative responses include impact on the professional, organization response, and lack of adequate resources and supports to prevent suicide. Previous research has examined the impact of suicide exposure among professionals specifically, but this is the first known study of participants in a community sample who identified the most impactful suicide attempt or death exposure they had experienced was that of a client in a mental health setting. Workplace exposure among mental health workers is common and can have both deleterious and positive effects. Bereavement focused outcomes, where the loss of an attachment relationship is the focus, does not capture the full range of experiences in workplace exposure. Systemic issues in mental health care contribute to further distress among exposed workers, and this requires additional investigation and response.

Suicide Among the Emergency Medical Systems Occupation in the United States

Introduction

Suicide claimed 47,173 lives in 2017 and is the second leading cause of death for individuals 15–34 years old. In 2017, rates of suicide in the United States (US) were double the rates of homicide. Despite significant research funding toward suicide prevention, rates of suicide have increased 38% from 2009 to 2017. Recent data suggests that emergency medical services (EMS) workers are at a higher risk of suicidal ideation and suicide attempts compared to the general public. The objective of this study was to determine the proportionate mortality ratio (PMR) of suicide among firefighters and emergency medical technicians (EMT) compared to the general US working population.

Methods

We analyzed over five million adult decedent death records from the National Occupational Mortality Surveillance database for 26 states over a 10-year non-consecutive period including 1999, 2003–2004, and 2007–2013. Categorizing firefighters and EMTs by census industry and occupation code lists, we used the underlying cause of death to calculate the PMRs compared to the general US decedent population with a recorded occupation.

Results

Overall, 298 firefighter and 84 EMT suicides were identified in our study. Firefighters died in significantly greater proportion from suicide compared to the US.working population with a PMR of 172 (95% confidence interval [CI], 153–193, P<0.01). EMTs also died from suicide in greater proportion with an elevated PMR of 124 (95% CI, 99–153), but this did not reach statistical significance. Among all subgroups, firefighters ages 65–90 were found to have the highest PMR of 234 (95% CI, 186–290), P<0.01) while the highest among EMTs was in the age group 18–64 with a PMR of 126 (95% CI, 100–156, P<0.05).

Conclusion

In this multi-state study, we found that firefighters and EMTs had significantly higher proportionate mortality ratios for suicide compared to the general US working population. Firefighters ages 65–90 had a PMR more than double that of the general working population. Development of a more robust database is needed to identify EMS workers at greatest risk of suicide during their career and lifetime.

Exposure to and experience of self-harm and self-harm related content: An exploratory network analysis

Exposure to the self-harm behaviour of others plays a role in individuals' own self-harm thoughts and behaviours, but there has been little consideration of the broader range of mediums through which exposure to self-harm related content may occur. N = 477 participants completed an online study, including questions regarding lifetime history of self-harm thoughts and behaviours and the frequency with which they had been exposed to self-harm via various mediums. Gaussian Markov random field network models were estimated using graphical LASSO and extended Bayesian information criterion. Bootstrapping revealed that exposure mediums with a direct connection to self-harm thoughts and behaviours were the internet (rrp = .34, 95% CI [.26, .42]) and in-passing 'miscellaneous' exposure (rrp = .14, 95% CI [.00, .23]). However, stability of the network centrality was low (expected influence stability = 0.52). The node with the greatest increase in expected influence within the network was miscellaneous "in-passing" exposure. In-passing exposure is an understudied exposure medium. Our results may suggest new types of exposure mediums for future research. Data were cross-sectional, so temporal relationships between exposure and behaviour could not be determined. Low stability of the networks suggests that future similar studies would benefit from larger sample sizes.

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.

Profiling Suicide Exposure Risk Factors for Psychological Distress: An Empirical Test of the Proposed Continuum of Survivorship Model

The Continuum of Survivorship proposes a way in which individuals may experience the suicide death of someone known to them along a continuum from being exposed to the death through to long-term bereavement. The present study provides a first empirical testing of the proposed model in an Australian community sample exposed to suicide. Using a Latent Profile Analysis, we tested the suicide exposure risk factors (time since death, frequency of pre-death contact, reported closeness, and perceived impact) to map to the Continuum of Survivorship model. Results revealed identification of five profiles, with four ranging from suicide exposed to suicide bereaved long-term broadly aligning with the proposed model, with one further profile being identified that represented a discordant profile of low closeness and high impact of suicide exposure. Our findings demonstrate that while the proposed model is useful to better understand the psychological distress related to exposure to suicide, it cannot be used as "shorthand" for identifying those who will be most distressed, nor those who may most likely need additional support following a suicide death. Implications and future research directions are discussed.

Occupational Suicide Exposure and Impact on Mental Health: Examining Differences Across Helping Professions

The purpose of the current study was to examine the relationship of suicide exposure with depression, anxiety, and post-traumatic stress disorder across three occupational groups likely to be exposed to suicide (i.e., first responders, crisis workers, mental health professionals). An online survey was completed by 1,048 participants. Results indicated that first responders, mental health professionals, and crisis workers were all exposed to suicide in the routine course of their occupation. Exposure to suicide significantly impacted mental health, specifically on depression, anxiety, and PTSD symptoms. The level of exposure to suicide was associated with higher levels of depression, anxiety, and PTSD.

'We're the First Port of Call' - Perspectives of Ambulance Staff on Responding to Deaths by Suicide: A Qualitative Study

Introduction

Exposure to suicide is a known risk factor for suicide. Ambulance staff are exposed to work-related stressors including attending suicides, which may elevate their risk for mental health problems/suicide. Little is known about ambulance staff’s perspectives on how they experience these events and whether they feel equipped to respond to bereaved families at the scene of death. This study explores the perspectives of ambulance staff about responding to deaths by suicide.

Materials and Methods

A convenience sample of ambulance staff recruited from one ambulance service in England. In-depth, qualitative, semi-structured face-to-face interviews conducted with nine ambulance staff (six male, three female) to explore experiences of responding to suicide. Data analyzed using thematic analysis.

Results

Participants reported the experience of job-related strain including exposure to the suicide/suicidal ideation of colleagues; they described suppressing their distress despite significant emotional impact. All participants had been personally bereaved by suicide and responding to suicide was a common part of their job. They were often the first professionals at the scene, and undertook varied and often conflicting roles: negotiating with patients in crisis; informing individuals of the death of a loved one; preserving the body/potential crime scene; dealing with the intense emotional reactions of bereaved individuals. Participants reported long-term, salient memories of these events; however, there was a reported lack of acknowledgment in the workplace that suicides may be traumatic and no guidance for staff on how to cope. Opportunities to debrief were reportedly rare, and there was reluctance to access work-based liaison services. Training in how to respond to individuals bereaved by suicide was also lacking.

Discussion

The study is the first to reveal the complex challenges faced by ambulance staff in responding to suicide without adequate training and support. It demonstrates the potential impact that responding to suicide can have personally and professionally on staff, and emphasizes the need for employers to support staff wellbeing in better ways. Training and postvention support could enable better coping among staff, more effective support for bereaved individuals and reduce the risk of death by suicide both in those bereaved by suicide and in ambulance staff.

Validation of the Suicidal Behavior Exposure Scale in First Responders

Background: First responders (e.g., emergency medical technicians, firefighters) may be at higher suicide risk than the general population due to frequent exposure to suicidal behaviors of others. Aims: We aimed to confirm the factor structure, scale reliability, and convergent validity of a new measure of suicidal exposure, the Suicidal Behaviors Exposure Scale, in first responders. Method: Using a cross-sectional web-based survey, we recruited 862 participants (81.3% male, mean age = 40.23, SD = 11.88) from a national database and southeastern state-based organization of first responders. Results: Confirmatory factor analysis resulted in a generally poor fit for the three-factor structure (exposure to suicidal communication, indirect exposure to suicide attempts/deaths, direct exposure to suicide attempts/deaths). However, good scale reliability and convergent validity were demonstrated. Limitations: The cross-sectional design, a convenience sample, and the low percentage of women comprise the limitations of this study. Conclusion: The Suicidal Behavior Exposure Scale requires additional development and validation before use in a first-responder sample. Future work should also examine other aspects of reliability and validity, namely, measurement invariance across groups and time.

Suicidal behaviors among American Indian/Alaska Native firefighters: Evidence for the role of painful and provocative events

Firefighters represent a group at elevated suicide risk. Identifying segments of the fire service at increased risk may facilitate the targeted provision of suicide prevention initiatives. Among the general population, American Indian/Alaska Native (AI/AN) individuals report higher rates of suicide attempts. This study sought to examine suicide attempt rates among AI/AN firefighters and to determine if greater exposure to painful and provocative events and/or fearlessness about death explains the relationship between AI/AN identity and suicidal behaviors. A total of 917 US firefighters completed a web-based mental health survey (6.2% AI/AN). Participants completed a modified version of the Self-Injurious Thoughts and Behaviors Interview-Short Form, the Painful and Provocative Events Scale, and the Acquired Capability for Suicide Scale-Fearlessness About Death scale. Bootstrap mediation analyses were conducted, controlling for years of service as a firefighter. Although AI/AN firefighters accounted for only 6.2% of the sample, they accounted for 34.4% of the career suicide attempts. AI/AN firefighters were 16.31 (95% CI = 7.96, 33.42) times more likely to report a career suicide attempt history than non-AI/AN firefighters, adjusting for years of service as a firefighter. Painful and provocative events, but not fearlessness about death, was a statistically significant mediator of the relationship between AI/AN identity and suicide attempts. Firefighters identifying as AI/AN represent a subgroup within the fire service at increased risk for suicide. Findings suggest that greater exposure to painful and provocative events among AI/AN firefighters may explain the elevated suicide risk among this population.

Sex Differences in Mental Health Outcomes of Suicide Exposure

Past research has robustly supported differences in prevalence and severity of mental health disorders between males and females in general. Less is known in regards to how suicide exposure and related factors may be associated with these mental health outcomes in men and women. This study seeks to explore similarities and differences between suicide exposure experiences of males and females in regards to number of exposures to suicide, relationships to the deceased, perceptions of closeness to the deceased, and related mental health correlates. Clinical applications are then discussed. A dual-frame, random digit dial survey was utilized to identify sex-differentiated demographic and suicide-related factors associated with these correlates in a statewide sample of 1,736 adults. t-tests revealed statistically higher depression, anxiety, and prolonged grief mean scores for suicide-exposed females; statistically higher suicide ideation levels in suicide-exposed males, and no statistical differences between sexes in PTSD scores. Logistic regression analyses provided an in-depth look at similarities and differences in risk and protective factors between male and female outcomes with perceptions of closeness and kinship levels as most salient risk factors. Cross-sectional design limits assertions of causality and retrospective nature of study may introduce recall bias. Males and females may differ in mental health impacts after suicide exposure. Implications for future research, prevention program planning, and bereavement counseling approaches are discussed.

Suicide among ambulance service staff: a review of coroner and employment records

Background:

There is growing evidence to suggest that ambulance service staff may be at increased risk for suicide; however, few studies have explored risk factors within this occupational group.

Aim:

To investigate factors commonly associated with ambulance staff suicides.

Method:

Eleven ambulance service trusts across the United Kingdom were asked to return details of staff suicides occurring between January 2014 and December 2015. Coroners were then contacted to request permission to review the records of the deceased.

Results:

Fifteen suicides were identified (73% male, mean age 42 years). Inquest data were available on 12 deaths. The most common method used was hanging. Possible risk factors identified included recent return to work following a period of sickness absence, poor mental health, relationship and debt problems, history of self-harm and the loss of a driving licence/change in job role.

Conclusion:

Identifying characteristics of suicide among this high-risk group is important to inform the development of suicide prevention initiatives. Additional research is needed with an adequate control group to further explore the risk factors identified in this study.

Factors Influencing the Mental Health of Firefighters in Shantou City, China

BACKGROUND

Firefighters are routinely exposed to occupational stress and are therefore vulnerable to psychological problems.

PATIENTS AND METHODS

This study assessed the prevalence of mental health symptoms and potential contributing factors in a sample of firefighters in Shantou city, in the Guangdong Province of China. We conducted a cross-sectional survey with 335 firefighters, including 329 male and 6 female firefighters. We used a questionnaire which assessed anxiety and depression, as indicated by the Zung Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS), as well as other mental health symptoms, using the Symptom Checklist-90 (SCL-90). Basic information and potential-related factors were also collected.

RESULTS

The average age of participants was 27.38 (SD ± 6.11) years. Assessed by the indexed score of different scales, SAS and SDS positive screening rates were 6.86% and 22.68%, respectively. SCL-90 scores indicated that 6.86% of participants had mental health symptoms. Logistic regression analysis showed that educational level, firefighter rank, and birth order were associated with mental health outcomes. Firefighters in Shantou were also shown to have better mental health outcomes than the Chinese military, but worse than the national population of firefighters.

CONCLUSION

These findings indicated the mental health of firefighters is not good. It is necessary to explore effective approaches to help preventing and treating mental disorder in firefighters.

Perceptions of belongingness and social support attenuate PTSD symptom severity among firefighters: A multistudy investigation

Firefighters experience high rates of posttraumatic stress disorder (PTSD). It is imperative to identify malleable factors that protect against the development of PTSD symptoms among this population. We examined whether perceptions of belongingness broadly (Study 1) and social support from supervisors, coworkers, and family/friends specifically (Study 2) are associated with lower PTSD symptom severity among firefighters. Study 1 included 840 U.S. firefighters (91.1% male); participants completed the Interpersonal Needs Questionnaire and PTSD Checklist-Civilian Version. Study 2 included 200 U.S. women firefighters exposed to a Criterion A traumatic event; participants completed the Generic Job Stress Questionnaire, Life Events Checklist for Diagnostic and Statistical Manual of Mental Disorders-5, and PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5. Linear regression analyses were conducted, adjusting for the number of years participants served as firefighters. Greater belongingness broadly (Study 1; b = -0.740, p < .001) as well as social support specifically (Study 2) from supervisors (b = -4.615, p < .001), coworkers (b = -4.465, p = .001), and family/friends (b = -3.206, p = .021) were associated with less severe PTSD symptoms. When all sources of social support were entered into a single model, only support from supervisors was significantly associated with lower overall PTSD symptom severity (b = -4.222, p = .004). Belongingness and social support may protect against the development of PTSD among firefighters. Supervisor social support may be particularly salubrious, suggesting that top-down mental wellness promotion within the fire service may be indicated to protect firefighters against PTSD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Suicide Exposure in Law Enforcement Officers

OBJECTIVE

To examine occupational and personal suicide exposure among Law Enforcement Officers (LEOs) and related mental health outcomes.

METHODS

Law Enforcement Officers (N = 813) completed an online survey about their suicide exposure, whether scenes stayed with them, and current symptoms of depression, anxiety, PTSD, and suicidal ideation.

RESULTS

Almost all participants (95%) had responded to at least one suicide scene with an average of 30.90 (SD = 57.28) career suicide scenes and 2.17 in the last year (SD = 4.11). One in five (22%) reported a scene that they cannot shake or have nightmares about, and 42.5% reported one scene that stayed with them. Almost three fourths (73.4%) knew someone personally who had died by suicide. There was a significant association between high levels of occupational exposure to suicide and behavioral health consequences including PTSD, persistent thoughts of a suicide scene, and the inability to shake a scene. The inability to shake a scene and having a scene stick with them was associated with increased symptoms of depression, anxiety, PTSD, and suicidal ideation.

CONCLUSIONS

LEOs experience a tremendous amount of exposure to suicide scenes and also have personal exposure. There is a need for training to mitigate the effect of these multiple traumas on their mental health.

Providing support following exposure to suicide: A mixed method study

Exposure to suicide and the associated impacts for those left behind can be long lasting and traumatic. Literature has predominantly examined the experience of suicide and impact from the perspective of those closest to the deceased-with studies primarily focused on kin relationships. Appropriate and timely support delivered by skilled professionals, through the provision of postvention support, has been suggested as a way to reduce morbidity and mortality associated with exposure to suicide. The evidence regarding what support, for whom, and the timing of support is scarce. As an extension of this scarcity, there is minimal research examining the ways in which provision of this postvention (that is, support following exposure to suicide) support impacts workers. This paper explores service use data gathered to evaluate a nation-wide Australian suicide postvention service, in conjunction with qualitative data from those providing postvention support to those exposed to suicide to understand who accesses support and the impact of providing such support on service providers. Postvention workers provide insight into the demands of responding to suicide, the pressure of being on call, and the ways in which they are able to maintain their well-being through external supervision.

A Preliminary Validation of the Suicidal Behavior Exposure Scale

OBJECTIVE

Research on suicide contagion has suggested that exposure to suicide-related thoughts and behaviors of others promotes one's personal risk for suicide. However, our understanding of the role suicidal exposure plays in the development of suicide risk is underdeveloped. This limited understanding may be due, in part, to the lack of a validated measure of exposure to suicidal behavior. The present study aimed to develop and validate a comprehensive self-report instrument of exposure to suicidal behaviors.

METHOD

Using two independent convenience samples of undergraduate students, exploratory structural equation modeling (ESEM) was performed on a newly developed measure of suicidal exposure.

RESULTS

Data supported a three-factor model of suicidal exposure: exposure to suicidal communication, direct exposure to suicide deaths and attempts, and indirect exposure to suicide deaths and attempts. Each factor demonstrated positive bivariate associations with depressive symptoms, posttraumatic stress disorder symptoms, suicide ideation, and suicide attempt history, suggesting convergent validity. Analyses demonstrated generally acceptable internal consistency.

CONCLUSION

This instrument will facilitate the study of suicidal exposure. Further validation of this scale, with attention to its reliability and invariance across gender and other demographic variables in clinically relevant samples, will be important for advancing the assessment of suicidal exposure and understanding its relation to suicide risk.

Suicide exposure and impact within a non-representative Australian community sample

The impact of exposure to suicide death or attempt remains ill-understood. This article aims to investigate this impact among 3010 community residing Australian adults. An online survey investigated the burden of exposure to suicide, psychological distress, and predictors of distress. The following variables were most significant in predicting distress among those exposed to suicide death: perceived impact of the most impactful death, non-kin relationship to the deceased, number of close suicide attempt exposures, time since the most impactful death, and frequency of contact. Results demonstrate suicide is a highly impactful experience and this impact reaches well beyond kin.

Occupational stress and suicidality among firefighters: Examining the buffering role of distress tolerance

Past research indicates that firefighters are at increased risk for suicide. Firefighter-specific occupational stress may contribute to elevated suicidality. Among a large sample of firefighters, this study examined if occupational stress is associated with multiple indicators of suicide risk, and whether distress tolerance, the perceived and/or actual ability to endure negative emotional or physical states, attenuates these associations. A total of 831 firefighters participated (mean [SD] age = 38.37y[8.53y]; 94.5% male; 75.2% White). The Sources of Occupational Stress-14 (SOOS-14), Distress Tolerance Scale (DTS), and Suicidal Behaviors Questionnaire-Revised (SBQ-R) were utilized to examine firefighter-specific occupational stress, distress tolerance, and suicidality, respectively. Consistent with predictions, occupational stress interacted with distress tolerance, such that the effects of occupational stress on suicide risk, broadly, as well as lifetime suicide threats and current suicidal intent, specifically, were attenuated at high levels of distress tolerance. Distress tolerance may buffer the effects of occupational stress on suicidality among firefighters. Pending replication, findings suggest that distress tolerance may be a viable target for suicide prevention initiatives within the fire service.

Exposure to suicide and suicide bereavement among women firefighters: Associated suicidality and psychiatric symptoms

OBJECTIVE

To examine experiences with suicide exposure and bereavement among women firefighters.

METHODS

Women firefighters (N = 266, M_age  = 37.64y) completed self-report measures assessing their experiences with suicide exposure, history of suicidality, current psychiatric symptoms, and suicide risk.

RESULTS

Three-fourths (74.4%) of participants reported knowing someone who had died by suicide; of these participants, 31.3% reported losing a fellow firefighter to suicide. Exposure to suicide during one's firefighting career was associated with more severe psychiatric symptoms and suicide risk. Greater impact of a suicide death was significantly associated with more severe current suicide risk, even after controlling for prior suicidality and other psychiatric symptoms.

CONCLUSIONS

Women firefighters exposed to suicide during their careers may experience more severe psychiatric symptoms and increased suicide risk as compared to their counterparts without this exposure. In particular, women firefighters who are more severely impacted by a suicide loss may be at increased suicide risk.

Anxiety sensitivity and suicide risk among firefighters: A test of the depression-distress amplification model

BACKGROUND

Firefighters represent an occupational group at increased suicide risk. How suicidality develops among firefighters is poorly understood. The depression-distress amplification model posits that the effects of depression symptoms on suicide risk will be intensified in the context of anxiety sensitivity (AS) cognitive concerns. The current study tested this model among firefighters.

METHODS

Overall, 831 firefighters participated (mean [SD] age = 38.37 y [8.53 y]; 94.5% male; 75.2% White). The Center for Epidemiologic Studies Depression Scale (CES-D), Anxiety Sensitivity Index-3 (ASI-3), and Suicidal Behaviors Questionnaire-Revised (SBQ-R) were utilized to assess for depression symptoms, AS concerns (cognitive, physical, social), and suicide risk, respectively. Linear regression interaction models were tested.

RESULTS

The effects of elevated depression symptoms on increased suicide risk were augmented when AS cognitive concerns were also elevated. Unexpectedly, depression symptoms also interacted with AS social concerns; however, consistent with expectations, depression symptoms did not interact with AS physical concerns in the prediction of suicide risk.

CONCLUSIONS

In the context of elevated depression symptoms, suicide risk is potentiated among firefighters reporting elevated AS cognitive and AS social concerns. Findings support and extend the depression-distress amplification model of suicide risk within a sample of firefighters. Interventions that successfully impact AS concerns may, in turn, mitigate suicide risk among this at-risk population.

Investigating the role of hopelessness in the relationship between PTSD symptom change and suicidality

BACKGROUND

This study served as an initial investigation of the role hopelessness may play in the relationship between PTSD symptom change and suicide intent, among a trauma-exposed, treatment-seeking sample. We explored whether the effect of PTSD symptom change on self-reported likelihood of a future suicide attempt (FSA) varies as a function of pre-treatment hopelessness, and whether reductions in hopelessness serve as a mechanism through which PTSD symptom change influences FSA likelihood.

METHODS

Data was collected from participants (N = 159) in a larger randomized clinical trial of a suicide risk-factor intervention. Self-report questionnaires assessed hopelessness, PTSD symptoms, depression symptoms, and FSA likelihood at pre-treatment and one-month follow-up.

RESULTS

Pre-treatment hopelessness emerged as a significant moderator, such that overall PTSD symptom reductions were related to overall decreases in FSA likelihood among those at or above (but not those below) the sample mean of pre-treatment hopelessness. In a subsample of individuals who reported FSA likelihood > 0 and elevated hopelessness at pre-treatment, overall pre-treatment-to-month-one reductions in hopelessness significantly mediated the relationship between overall PTSD symptom reductions and decreased FSA likelihood during this same time period, even after accounting for depression symptom changes.

LIMITATIONS

Data were limited to self-report measures (i.e., hopelessness, FSA likelihood). The intervention was not PTSD-specific. Mediation analyses were strictly statistical due to overlapping time-points.

CONCLUSIONS

This preliminary investigation suggests pre-treatment hopelessness may serve to identify trauma-exposed individuals for whom PTSD treatment would significantly reduce FSA likelihood. Moreover, reductions in FSA likelihood during treatment may be due in part to reduced hopelessness.

Examining Physical and Sexual Abuse Histories as Correlates of Suicide Risk Among Firefighters

Research indicates that physical and sexual abuse are associated with increased suicide risk; however, these associations have not been investigated among firefighters-an occupational group that has been shown to be at elevated suicide risk. This study examined whether physical and sexual abuse histories are associated with (a) career suicide ideation, plans, and attempts; and (b) current suicide risk (controlling for theoretically relevant symptoms) in this occupational group. A sample of 929 U.S. firefighters completed self-report surveys that assessed lifetime history of physical and sexual abuse; career suicide ideation, plans, and attempts; current suicide risk; and theoretically relevant symptoms. Logistic regression analyses revealed that individuals who reported a history of physical abuse were significantly more likely to report career suicide ideation, adjusted odds ratio [AOR] = 6.12, plans, AOR = 13.05, and attempts, AOR = 23.81, than those who did not. A similar pattern of findings emerged for individuals who reported a sexual abuse history, AORs = 7.83, 18.35, and 29.58 respectively. Linear regression analyses revealed that physical and sexual abuse histories each significantly predicted current suicide risk, even after controlling for theoretically relevant symptoms and demographics, pr² = .07 and .06, respectively. Firefighters with a history of physical and/or sexual abuse may be at increased risk for suicidal thoughts and behaviors. A history of physical and sexual abuse were each significantly correlated with current suicide risk in this population, even after accounting for the effects of theoretically relevant symptoms. Thus, when conceptualizing suicide risk among firefighters, factors not necessarily related to one's firefighter career should be considered.

Suicidal thoughts and behaviors among women firefighters: An examination of associated features and comparison of pre-career and career prevalence rates

BACKGROUND

Women protective service workers die by suicide at a higher rate than women workers in other occupational groups. However, no study has examined rates and correlates of suicidal thoughts and behaviors among women firefighters, despite the potential for these data to inform suicide screening, prevention, and intervention initiatives. The purpose of this study is to describe and compare pre-career and career rates of suicidal thoughts and behaviors and identify their sociodemographic and occupational correlates among women firefighters.

METHODS

Data were obtained from 313 current U.S. women firefighters who completed a web-based survey (mean age = 37.30y, SD = 9.70y, 92.7% White).

RESULTS

Pre-career rates of suicide ideation, plans, attempts, and non-suicidal self-injury (NSSI) were found to be 28.4%, 10.2%, 5.8%, and 11.2%, respectively. Career rates of suicide ideation, plans, attempts, and NSSI were found to be 37.7%, 10.9%, 3.5%, and 9.3%, respectively. Pre-career rates of suicide ideation (OR = 4.760, 95% CI = 2.820-8.034, p < 0.001), plans (OR = 4.867, 95% CI = 2.067-11.463, p < 0.001), attempts (OR = 7.175, 95% CI = 1.726-29.828, p = 0.007), and NSSI (OR = 9.676, 95% CI = 4.130-22.670, p < 0.001) were significantly associated with career suicidality. With few exceptions, neither sociodemographic characteristics nor firefighter experiences were associated with career suicidal symptoms.

LIMITATIONS

Study limitations include a cross-sectional design and convenience sample recruitment strategy.

CONCLUSIONS

Women firefighters report elevated rates of suicidal thoughts and behaviors. Suicidal symptoms occurring prior to one's tenure as a firefighter-and not solely an aspect of firefighter career experiences-should be considered in suicide risk screening, prevention, and intervention initiatives. Studies examining modifiable suicide risk factors and correlates (e.g., psychiatric symptoms, workplace harassment) are needed.

Differences in psychiatric symptoms and barriers to mental health care between volunteer and career firefighters

Firefighters are at increased risk for mental health problems. However, little is known about differences in psychiatric symptoms between volunteer and career firefighters. This study aimed to (1) describe differences in psychiatric symptoms and barriers to mental health care between U.S. firefighters in volunteer-only and career-only departments; and (2) determine if greater self-reported structural barriers to mental health care (e.g., cost, availability of resources) explain the differences in psychiatric symptom levels. Overall, 525 current U.S. firefighters participated. Analyses of covariance and logistic regression analyses were used to evaluate group differences between volunteer (n=204) and career (n=321) firefighters, adjusting for demographic and occupational characteristics. Volunteer firefighters reported significantly elevated levels of depression, posttraumatic stress, and suicidal symptoms compared to career firefighters. Career firefighters reported relatively elevated levels of problematic alcohol use. Volunteer firefighters additionally reported greater structural barriers to mental health care (e.g., cost, availability of resources), and these barriers accounted for the differences in mental health variables between volunteer and career firefighters. Findings suggest that volunteer firefighters report elevated psychiatric symptoms compared to career firefighters and greater structural barriers to mental health treatment may explain this link. Increased efforts are needed to develop firefighter-specific interventions and bolster mental health service utilization.