Firefighters, posttraumatic stress disorder, and barriers to treatment: Results from a nationwide total population survey

Risks of occupational mental disorders in Korean civil servants (2009-18)

BACKGROUND

Previous studies have suggested that firefighters, police officers and civil servants in the education sector, particularly in Western countries, are vulnerable to mental stress and disorders; however, evidence for this association in South Korea is lacking.

AIMS

This study aimed to identify whether firefighters, police officers and teachers are at a higher risk for occupational mental health disorders.

METHODS

We used workers' compensation claims from civil servants (2009-18). Our target population comprised 46 209 civil servants (9009 civil servants in administrative and technical positions, 23 107 police officers, 4417 firefighters and 8676 civil servants in the educational sector). Occupational and environmental medicine physicians and medical doctors defined and confirmed mental disorders. We conducted Cox proportional hazards regression analyses to evaluate civil servants' risk of occupational mental health disorders.

RESULTS

Compared with the civil servants in administrative and technical positions, civil servants in the education sector (hazard ratio [HR] = 2.16; 95% confidence interval [CI]:1.65-2.84) showed a statistically significant increased risk of mental disorders; conversely, firefighters did not (HR = 0.80; 95% CI 0.51-1.27). Police officers had a significantly decreased mental disorder risk compared with civil servants in administrative and technical positions (HR = 0.17; 95% CI 0.11-0.25).

CONCLUSIONS

The risk of occupational mental health disorders was higher in civil servants in the education sector but lower in police officers and firefighters than civil servants in administrative and technical positions. Further studies on civil servants' mental health awareness are required to confirm our results.

The prevalence of post-traumatic stress disorder among emergency medical services personnel in Saudi Red Crescent Authority, Riyadh, Saudi Arabia

Background

Determining the prevalence of PTSD and contributing variables among (EMS) specialists was the goal of the current investigation. Furthermore, limited evidence exists regarding the application of PCL-5 for EMT practitioners, and the incidence of PTSD among different age groups and genders in Saudi Arabia.

Methods

This cross-sectional descriptive study includes 211 prehospital care providers of the Saudi Red Crescent Authority stations in Riyadh. The randomization was done using Google Forms into subgroups according to participants' gender, years of experience, occupations, and average working hours. The presence and severity of PTSD symptoms were evaluated using the 20-item PTSD Checklist for DSM-5 (PCL-5) self-report questionnaire. Data were analyzed using Pearson Chi-Square, Mann-Whitney and Kruskal-Wallis tests. The reliability statistics were calculated using Cronbach's Alpha for the 20-survey questionnaire.

Results

The comparison of PCL-5 total scores indicated more PTSD symptomatology among females (1.61 + 0.799) as compared to male workers (1.13 + 0.642). The total score of PTSD demonstrated no statistically significant (P=0.79) differences between our age group classifications. In terms of the participants' city (Riyadh), the total PTSD score was less than the cutoff point which is 31. PTSD total score may not be affected by working experience as indicated by the non-significant difference in prevalence among EMT practitioners having <5 years, 5-10 years and above 10 years of working experience (P=0.215 with X2 = 3.076). PTSD incidence is affected by the type of occupation as statistically significant differences between groups (P=0.001) were recorded depending on the position and responsibilities of EMS practitioners. PTSD is also affected by average working hours per week, and there were statistically significant differences between groups (P=0.001).

Conclusion

The total score of PTSD in the case of emergency service practitioners was found to be 33.7% among all the research participants, which may be regarded as a high prevalence when compared to the general population. Our investigations would contribute to a better understanding of the underlying factors of mental stress in EMS specialists in Saudi Arabia and to the development of adequate mental health practices.

Firefighters' medical use and Korean Medicine experience in Korea: A qualitative study protocol

INTRODUCTION

Firefighters, compared to other occupational groups, are exposed more frequently in their working environment not only to physical issues, such as musculoskeletal disease, respiratory disease, and burns but also to mental health issues, such as PTSD and depression. Specifically, Korean firefighters experience significantly higher rates of work-related injuries compared to those in other countries. Recent statistics from the Korea National Fire Agency indicate a steady increase in the number of firefighting work-related injuries. However, there is a shortage of measures in place to address these issues. This study aims to investigate the health needs, overall healthcare usage, and unmet needs of firefighters in Korea. We also aim to investigate, through in-depth interviews, perceptions and hindering factors for integrative medicine approaches to fulfilling unmet needs.

METHOD

This study was conducted in accordance with the consolidated criteria for reporting qualitative research. Convenience and snowball sampling methods will be used to recruit firefighters to participate in the study, and interviews will be conducted using a semi-structured interview guide. The data will be analyzed in four stages using the qualitative analysis method of Krippendorff.

DISCUSSION

In this study, we examine the state of health issues and healthcare usage among Korean firefighters and investigate their perceptions of and needs for integrative medicine. In this way, we aim to explore how integrative medicine and Korean medicine approaches could improve and assist healthcare services for firefighters. Furthermore, our findings will provide policymakers and healthcare providers with the necessary basic information to develop integrative medicine systems suited to firefighters.

AOA Critical Issues Symposium: Gun Violence as a Public Health Crisis

ABSTRACT

Gun violence is an epidemic throughout the United States and is increasing around the world-it is a public health crisis. The impact of gun violence is not limited to the victims (our patients); it also extends to the physicians and caregivers who are taking care of these patients every day. Even more broadly, gun violence affects those living and going to work in potentially dangerous environments. The "vicarious trauma" that is experienced in these situations can have long-term effects on physicians, nurses, and communities. Importantly, socioeconomic disparities and community deprivation strongly correlate with gun violence. Systemic factors that are deeply ingrained in our society can increase concerns for these underrepresented patient populations and cause increased stressors with substantial health consequences, including delayed fracture-healing and poorer overall health outcomes. It is incumbent on us as physicians to take an active role in speaking up for our patients. The importance of advocacy efforts to change policy (not politics) and continue to push for improvement in the increasingly challenging environments in which patients and physicians find themselves cannot be overstated. Multiple national organizations, including many orthopaedic and general surgery associations, have made statements advocating for change. The American College of Surgeons, in collaboration with many other medical organizations, has supported background checks, registration, licensure, firearm education and training, safe storage practices, red flag laws, addressing mental health issues, and more research to better inform an approach going forward and to address the root causes of violence. We encourage the orthopaedic surgery community to stand together to protect each other and our patients, both physically and mentally, with agreement on these principles.

Dean Y, Kishk RM, Elsaid NMAB, Salem A, Shah J, Aiash H, Eida M. Assessment of post-traumatic stress disorder and health-related quality of life among patients recovered from mild-to-moderate COVID-19 and their close contacts: A cross-sectional study

The pandemic of COVID-19 is a traumatic event with distressing implications for mental health and several aspects of life. This study aimed to assess Post-traumatic Stress Disorder (PTSD) and Health-Related Quality of Life (HRQoL) among patients who experienced mild-to-moderate COVID-19 and their household contacts. This cross-sectional descriptive study was conducted between May 2020 and November 2020, in Ismailia and Suez governorates. A convenient sampling method was used. The sample size was calculated according to the prevalence of PTSD in COVID-19 patients to be 200 adult participants from both sexes, 100 patients with history of recent COVID-19 infection (up to 2 months after recovery) and their close family. COVID-19 was confirmed by a nasal swab sample tested by PCR in addition to suggestive symptoms and/or positive computed tomography lung findings. Data was collected by using the Arabic version of the Post-Traumatic Stress disorder checklist 5 (PCL5-PTSD) and the Arabic version of Health-Related Quality of Life (HRQoL). The questionnaire was collected through interviews at the Endemic and Infectious diseases and Family medicine outpatient clinics. Of the 200 studied participants, evidence of PTSD was found in 112 (56%) participants; all COVID-19 cases and 12 of their close-contact relatives. Impaired HRQoL was evident in 107 (53.5%) participants; all the COVID-19 cases and 7 contacts. The mean values total scores of the PTSD and HRQoL and its domains were significantly higher among cases compared to their contacts. The most frequently impaired domain was social (55%), psychological (54.5%), impairment (53.5%) followed by physical (48.5%) and the least was health perception (33.5%). The mean values of PTSD, HRQoL and their domains were significantly higher among participants who recalled respiratory symptoms and who had comorbid illness. The odds ratio of PTSD and HRQoL was 0.27 (95% CI: 0.2-0.36) and 0.3 (95% CI: 0.23-0.39) in participants who had more than a case of COVID-19 within their families. All the studied COVID-19 participants showed PTSD and impaired HRQoL, compared to 12% and 7% of their contacts, respectively. Past COVID-19 was associated with impairment of all domains of HRQoL and the most affected were the physical, psychological and impairment domains.

Stress response and experiential avoidance among firefighters: Preliminary insights from network analyses

Firefighters are at increased risk of developing posttraumatic stress disorder (PTSD) due to exposure to potentially traumatic events during their careers. However, little is known about the prevalence of PTSD among this population, particularly when taking moderating variables into account. Using Gaussian Graphical Models and Directed Acyclic Graphs, we conducted network analyses to examine the interactions between clusters of PTSD symptoms, perceived stress, hardiness, and experiential avoidance among 187 firefighters. The data and code are published with the paper. Experiential avoidance, as part of psychological inflexibility, was found to be the only variable that interacted with PTSD symptomatology. Strong positive associations were observed between experiential avoidance and the "negative mood and cognitions" subscale of the PTSD Checklist for DSM-5 (PCL-5). Through this association, other PTSD symptoms were activated, particularly avoidance and arousal. Our findings suggest that experiential avoidance and negative mood and cognition symptoms are particularly important in the expression of PTSD symptomatology in firefighters. In addition, experiential avoidance may be used as a coping strategy to reduce perceived stress during potentially traumatic events. Therefore, experiential avoidance may be a prime target for future interventions and training focused on flexible self-regulation strategies in this population.

Developing and Evaluating an Online Post-Traumatic Growth Program for Firefighters

We evaluated how an online post-traumatic growth program affected rumination, social support, and post-traumatic growth. We recruited 33 firefighters from two Korean provinces and employed a nonequivalent control group pretest-post-test design. We administered the pretest for the intervention group (n = 16), consisting of eight sessions with an online workbook and messenger group counseling. We conducted post-tests immediately after the program and 4 weeks later. Post-traumatic growth and social support increased significantly. There were no statistically significant differences for intrusive or deliberate rumination. Psychological support programs should be developed to reflect firefighters' work characteristics and needs, including programs designed to induce rumination.

Adapting the Primary Care PTSD Screener for firefighters

BACKGROUND

By the nature of their work, first responders are at risk for post-traumatic stress disorder (PTSD). Efficient screening instruments are useful to identify at-risk first responders and connect them to services.

AIMS

The current study aimed to (i) evaluate the diagnostic properties of the Primary Care PTSD for DSM-5 (PC-PTSD-5) scale among firefighters, (ii) explore the use of an adapted PC-PTSD-5 on a five-point Likert-type scale and (iii) examine sensitivity and specificity of the adapted instrument in this population.

METHODS

Pooled data were analysed among firefighters (N = 92) from a treatment-seeking sample (n = 36) and a population health screening sample (n = 56). Participants completed an adapted version of the PC-PTSD-5 and the Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5). Receiver operating characteristic curve analyses were performed, referencing PCL-5 cut-off/probable diagnostic threshold scores.

RESULTS

The PC-PTSD-5 demonstrated excellent operating characteristics overall. A threshold of 3 was optimal for discriminating probable PTSD using a proxy for the original PC-PTSD-5 (range: 0-5), whereas a score of 9 was identified for the PC-PTSD-5 permutation that allowed for more response variability (range: 0-20).

CONCLUSIONS

Our preliminary data suggest the PC-PTSD-5 may be a useful tool for brief firefighter screening, with suggested cut-offs that require further replication and expanded investigation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Understanding Mental Health Needs and Gathering Feedback on Transcutaneous Auricular Vagus Nerve Stimulation as a Potential PTSD Treatment among 9/11 Responders Living with PTSD Symptoms 20 Years Later: A Qualitative Approach

Posttraumatic stress disorder (PTSD) remains one of the most prevalent diagnoses of World Trade Center (WTC) 9/11 responders. Transcutaneous auricular vagus nerve stimulation (taVNS) is a potential treatment for PTSD, as it can downregulate activity in the brain, which is known to be related to stress responses and hyperarousal. To understand barriers and facilitators to engagement in mental health care and the feasibility and acceptability of using the taVNS device as a treatment for PTSD symptoms, a focus group was conducted among patients from the Queens WTC Health Program who had elevated symptoms of PTSD. The focus group discussion was recorded, transcribed, and analyzed. Three themes and subthemes emerged: (1) the continued prevalence of mental health difficulties and systematic challenges to accessing care; (2) positive reception toward the taVNS device as a potential treatment option, including a discussion of how to increase usability; and (3) feedback on increasing the feasibility and acceptance of the research methodology associated with testing the device in a pilot clinical trial. The findings highlight the need for additional treatment options to reduce PTSD symptoms in this population and provide key formative phase input for the pilot clinical trial of taVNS.

Dynamic Psychotherapy as a PTSD Treatment for Firefighters: A Case Study

In Portugal, forest fires are responsible for disasters that tend to be repeated annually, leading to dramatic consequences, such as those that have occurred in 2017, with the destruction of hundreds of houses and the deaths of dozens of people. Firefighters who are exposed to these potentially traumatic events are considered a high-risk group for the development of stress-related disorders. The aim of this study was to monitor the progress of two firefighters with symptoms of post-traumatic stress disorder (PTSD) treated through dynamic psychotherapy (DP) and to assess the feasibility of implementing this intervention within fire departments. A female firefighter and a male firefighter, with similar sociodemographic characteristics and PTSD symptom severity, were selected to verify the treatment applicability for both genders. The symptomatology changes were assessed through a set of instruments (PHQ-15, PCL-5, BSI, DASS, and CALPAS-P) applied every three months over 15 months (including pre-treatment, treatment period, and post-treatment). DP seemed to be an effective treatment for PTSD symptoms, with patients showing a state of increasing improvement even after the end of treatment. The acceptability to firefighters, the treatment adherence, the therapeutic alliance, and the reduction in PTSD symptoms suggest feasibility for implementing this intervention inside the Portuguese fire departments.

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

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

Mental health care utilization by first responders after Paris attacks

Background

First responders (FRs) are frequently exposed to potentially traumatic events, including terror attacks, and may consequently be at risk of developing mental health disorders. Prior research suggests that FRs with mental health disorders often do not receive appropriate treatment. More knowledge is needed about their use of mental health care (MHC).

Aims

This study aimed to identify factors associated with receiving immediate support, post-immediate support and engagement in MHC among FRs of the November 2015 terror attacks in Paris.

Methods

A web-based study was conducted 8–12 months after the attacks on 663 FRs who were mobilized during the night and/or the aftermath of the attacks. Logistic regression was performed to analyse factors associated with MHC.

Results

Overall, 44 FRs sought MHC. Among FRs with post-traumatic stress disorder (PTSD), partial PTSD or depression (n = 60), 38% sought MHC (n = 23). Post-immediate support was associated with immediate support, and both were associated with knowing someone who could help regarding the potential psychological risks following a traumatic event. MHC engagement was associated with a history of MHC, post-immediate support and the presence of PTSD, partial PTSD or depression.

Conclusions

Among FRs with PTSD, partial PTSD or depression, few sought MHC. Improved access to MHC for FRs after terror attacks is essential. Knowing someone who could help regarding potential psychological risks may facilitate immediate and/or post-immediate support. Furthermore, post-immediate support could encourage engagement in MHC. Efforts should be made before and after potentially traumatic events to ensure mental health education for FR.

Identifying the risk features for occupational stress in medical workers: a cross-sectional study

Objective

Occupational stress is considered a worldwide epidemic experienced by a large proportion of the working population. The identification of characteristics that place people at high risk for occupational stress is the basis of managing and intervening in this condition. In this study, we aimed to identify and validate the risk features for occupational stress among medical workers using a risk model and nomogram.

Methods

This cross-sectional study included 1988 eligible participants from Henan Province in China. Occupational stress and worker-occupation fit were measured with the Depression, Anxiety and Stress Scales (DASS-21) and Worker-Occupation Fit Inventory (WOFI). The identification of risk features was achieved through constructing multiple logistic regression model, and the risk features were used to develop the risk model and nomogram. Receiver operating characteristic (ROC) curves and calibration plots were generated to assess the effectiveness and calibration of the risk model.

Results

Among 1988 participants in our study, there were 42.5% (845/1988) medical workers experienced occupational stress. The risk features for occupational stress included poor work-occupation fit (WOF score < 25, expected risk: 77.3%), nurse population (expected risk: 63.1%), male sex (expected risk: 67.2%), work experience duration of 11–19 years (expected risk: 54.5%), experience of a traumatic event (expected risk: 65.3%) and the lack of a regular exercise habit (expected risk: 60.2%). For medical workers who have these risk features, the expected risk probability of occupational stress would be 90.2%.

Conclusion

The current data can be used to identify medical workers at risk of developing occupational stress. Identifying risk features for occupational stress and the work-occupation fit can support hierarchical stress management in hospitals.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-021-01762-3.

Job Demands and Exhaustion in Firefighters: The Moderating Role of Work Meaning. A Cross-Sectional Study

Emotional exhaustion and other symptoms of burnout are often found among emergency services professions, such as firefighting. Given the social importance of this activity and the high responsibility it requires, prevention and alleviation of burnout symptoms become primary concerns in ensuring the well-being of firefighters. Although work meaning is one of the factors associated with a lower risk of developing burnout, its protective role has not been studied in firefighters. Therefore, the purpose of this study was to assess the buffering role of work meaning in the health-impairment process of the Job Demands-Resources model, targeting the relationship between job demands and related emotional exhaustion. A cross-sectional survey design was used to collect data from a sample consisting of Romanian firefighters (n = 1096). Structural equation modeling indicated a positive link between job demands and exhaustion. In addition, deriving personal meaning from work was associated with lower levels of exhaustion in firefighters. A small but significant interaction effect between work meaning and job demands showed that higher levels of work meaning attenuated the positive relationship between job demands and exhaustion. In conclusion, our findings suggest that work meaning has a buffering effect on the impact of various job demands on job-related exhaustion. Nevertheless, the small effect sizes warrant further research on this topic.

Trauma and Mental Health Awareness in Emergency Service Workers: A Qualitative Evaluation of the Behind the Seen Education Workshops

Emergency service workers (ESWs) are at high risk of experiencing poor mental health, including posttraumatic stress disorder (PTSD). Programs led by ex-service organizations may play an unrecognized but critical role in mental health prevention and promotion. Behind the Seen (BTS) is an Australian ex-service organization that runs workshops to raise awareness and facilitate conversations around the mental health of ESWs. The purpose of the study is to conduct a qualitative evaluation of workshop participants’ experiences, to understand the acceptability and perceived usefulness over the immediate- (within 1 month), intermediate- (6 months) and longer-terms (12 months). Participants (n = 59 ESWs) were recruited using purposive sampling across five fire and rescue services in metropolitan, regional, and rural locations. Focus groups methodology was used for data collection and data were analyzed using iterative categorization techniques. Participants reported (i) a high perceived need for education about PTSD, (ii) highly salient aspects of the presentation that made for a positive learning experience, including the importance of the lived experiences of the facilitators in the learning process, (iii) key features of changes to intentions, attitudes, and behavior, and (iv) major aspects of the organizational context that affected the understanding and uptake of the program’s key messages. BTS was perceived as an acceptable means of delivering mental health, PTSD, and help-seeking information to ESWs. The program is a promising candidate for scaling-up and further translation.

On being a client with posttraumatic stress disorder: Interactions with treatment providers and institutional barriers

Premature dropout from psychological treatment for posttraumatic stress disorder (PTSD) is common. Little research has sought to understand perceptions of treatment and barriers to treatment in this population. This study analyzed anonymous posts among an online community of individuals with PTSD (93 forum users comprising 158 posts regarding treatment providers and 40 forum users comprising 50 posts regarding institutional barriers). Results indicated that individuals with PTSD desire greater clarity about expectations for treatment, collaboration toward treatment goals, open discussion of client-therapist boundaries, and increased validation among therapists in response to trauma disclosure. Individuals with PTSD also reported multiple systemic issues that were barriers to treatment including a lack of available services in their area, being placed on a waitlist for long periods of time, the cost of treatment as a financial burden, and poor crisis response in emergency rooms. Findings indicated areas of growth for treatment providers which will help inform future treatment studies in improving care and treatment adherence among individuals with PTSD.

Prospective risk and protective factors for psychopathology and wellbeing in civilian emergency services personnel: a systematic review

Emergency services personnel have an elevated risk of developing mental health conditions. Most research in this area is cross-sectional, which precludes inferences about temporal and potentially causal relationships between risk and protective factors and mental health outcomes. The current study systematically reviewed prospective studies of risk and protective factors for mental health outcomes in civilian emergency services personnel (firefighters, paramedics, police) assessed at pre-operational and operational stages. Out of 66 eligible prospective studies identified, several core groups of risk and protective factors emerged: (1) cognitive abilities; (2) coping tendencies; (3) personality factors; (4) peritraumatic reactions and post-trauma symptoms; (5) workplace factors; (6) interpersonal factors; (7) events away from work. Although there was insufficient evidence for many associations, social support was consistently found to protect against the development of mental health conditions, and peritraumatic dissociation, prior mental health issues, and prior trauma exposure were risk factors for future mental health conditions. Among operational studies, neuroticism was significantly associated with future PTSD symptoms, burnout, and general poor mental health, and avoidance and intrusion symptoms of PTSD were associated with future PTSD and depression symptoms. The current review results provide important targets for future research and interventions designed to improve the mental health of emergency services personnel.

Post-traumatic stress disorder in train crash survivors in Italy: the role of mood spectrum dysregulations and intrusiveness

BACKGROUND

To explore relationships among post-traumatic stress disorder (PTSD), depressive spectrum symptoms, and intrusiveness in subjects who survived the crash of a train derailed carrying liquefied petroleum gas and exploded causing a fire.

METHODS

A sample of 111 subjects was enrolled in Viareggio, Italy. AMOS version 21 (IBM Corp, 2012) was utilized for a structural equation model-path analysis to model the direct and indirect links between the exposure to the traumatic event, the occurrence of depressive symptoms, and intrusiveness. Subjects were administered with the SCID-IV (Structured Clinical Interview for DSM-IV), the Questionnaire for Mood Spectrum (MOODS-SR)-Last Month version, the Trauma and Loss Spectrum Questionnaire (TALS-SR), and the Impact of Event Scale-Revised version (IES-R).

RESULTS

Sixty-six (66/111; 59.4%) subjects met SCID-IV criteria for PTSD. Indices of goodness of fit were as followed: χ2/df = 0.2 P = .6; comparative fit index = 1 and root mean square error of approximation = 0.0001. A significant path coefficient for direct effect of potential traumatic events on depressive symptoms (β = 0.25; P < .04) and from depressive symptoms to intrusiveness (β = 0.34; P < .003) was found. An indirect effect was also observed: standardized value of potential traumatic events on intrusiveness was 0.86. The mediating factor of this indirect effect path was represented by depressive symptoms. Potential traumatic events explained 6.2% of the variance of depressive symptoms; 11.8% of the variance of intrusiveness was accounted for traumatic event and depressive symptoms.

CONCLUSIONS

Path analysis led us to speculate that depression symptoms might have mediated the relationship between the exposure to potential traumatic events and intrusiveness for the onset of PTSD.

Firefighters Have Cerebral Blood Flow Reductions in the Orbitofrontal and Insular Cortices That are Associated with Poor Sleep Quality

PURPOSE

To investigate the cerebral blood flow (CBF) alterations associated with poor sleep quality and memory performance in firefighters.

PARTICIPANTS AND METHODS

Thirty-seven firefighters (the FF group) and 37 non-firefighter controls (the control group) with sleep complaints were enrolled in this study. We performed brain arterial spin labeling perfusion magnetic resonance imaging (MRI) and compared the CBF between the two groups using whole-brain voxel-wise analyses. Self-reported sleep problems and actigraphy-measured sleep parameters, including the sleep efficiency, wake after sleep onset (WASO), total sleep time, and sleep latency, were assessed. Spatial working memory and learning performances were evaluated on the day of the MRI scan.

RESULTS

The FF group, relative to the control group, had lower CBF in the right hemispheric regions: Middle temporal/lateral occipital, orbitofrontal, and insular cortices. Lower CBF in the right orbitofrontal cortex was linearly associated with poor sleep quality, as indicated by lower sleep efficiency and longer WASO. The CBF of the right insular cortex was also associated with longer WASO. Despite comparable degrees of self-reported sleep problems between the two groups, the FF group had lower sleep efficiency and longer WASO in the actigraphy, and lower spatial working memory and learning performance, relative to the control group. Poor sleep efficiency was linearly associated with lower spatial working memory performance.

CONCLUSION

These results demonstrated an association of poor sleep quality with decreased brain perfusion in the right orbitofrontal and insular cortices, as well as with reduced working memory performance.

Probable PTSD, depression and anxiety in 40,299 UK police officers and staff: Prevalence, risk factors and associations with blood pressure

INTRODUCTION

Police employees undertake challenging duties which may adversely impact their health. This study explored the prevalence of and risk factors for probable mental disorders amongst a representative sample of UK police employees. The association between mental illness and alterations in blood pressure was also explored.

METHODS

Data were used from the Airwave Health Monitoring Study which was established to monitor the possible physical health impacts of a new communication system on police employees. Data included sociodemographic characteristics, lifestyle habits, depression, anxiety, and post-traumatic stress disorder (PTSD) symptoms and blood pressure. Descriptive statistics were used to explore the prevalence of probable mental disorders and associated factors. Stepwise linear regression was conducted, controlling for confounding variables, to examine associations between mental disorders and blood pressure.

RESULTS

The sample included 40,299 police staff, police constable/sergeants and inspectors or above. Probable depression was most frequently reported (9.8%), followed by anxiety (8.5%) and PTSD (3.9%). Groups at risk for probable mental disorders included police staff, and police employees who reported drinking heavily. Police employees exposed to traumatic incidents in the past six months had a doubling in rates of anxiety or depression and a six-fold increase in PTSD compared to those with no recent trauma exposure. Adjusted logistic regression models did not reveal any significant association between probable mental disorders and systolic blood pressure but significantly elevated diastolic blood pressure (≈1mmHg) was found across mental disorders.

CONCLUSIONS

These results show lower rates of probable mental disorders, especially PTSD, than reported in other studies focusing on police employees. Although mental ill health was associated with increased diastolic blood pressure, this was unlikely to be clinically significant. These findings highlight the importance of continued health monitoring of members of the UK police forces, focusing on employees recently exposed to traumatic incidents, heavy drinkers and police staff.

The Quality, Readability, Completeness, and Accuracy of PTSD Websites for Firefighters

Firefighters appear at an increased risk for post-traumatic stress disorder (PTSD). Because of PTSD-related stigma, firefighters may search for information online. The current study evaluated the quality, readability, and completeness of PTSD online resources, and to determine how the online treatment recommendations align with current evidence. Google.ca (Canada) searches were performed using four phrases: ‘firefighter PTSD’, ‘firefighter operational stress’, ‘PTSD symptoms’, and ‘PTSD treatment’. The 75 websites identified were assessed using quality criteria for consumer health information (DISCERN), readability and health literacy statistics, content analysis, and a comparison of treatments mentioned to the current best evidence. The average DISCERN score was 43.8 out of 75 (indicating ‘fair’ quality), with 9 ‘poor’ websites (16–30), 31 ‘fair’ websites (31–45), 26 “good” websites (46–60), and nine excellent websites (61–75). The average grade level required to understand the health-related content was 10.6. The most mentioned content was PTSD symptoms (48/75 websites) and PTSD treatments (60/75 websites). The most frequently mentioned treatments were medications (41/75 websites) and cognitive behavioural therapy (40/75 websites). Cognitive behavioural therapy is supported by strong evidence, but evidence for medications appears inconsistent in current systematic reviews. Online PTSD resources exist for firefighters, but the information is challenging to read and lacks evidence-based treatment recommendations.

Prevalence of Posttraumatic Stress Disorder among Firefighters in Iran: A Systematic Review and Meta-Analysis

Objective: Firefighters are exposed to many different chemicals and physical hazards and experience a significant number of accidents and injuries. They are exposed to high-risk of posttraumatic stress disorder (PTSD).

The purpose of this study was to determine the prevalence of PTSD among Iranian firefighters.

Method: This was a systematic review and meta-analysis. Valid Persian and English keywords were searched in data resources, including SID, Magiran, Irandoc, Google Scholar, PubMed, Scopus, and Web of Science to retrieve articles on the prevalence of PTSD among Iranian firefighters. The STROBE checklist was used to assess the quality of the articles. Heterogeneity among the studies was assessed by I² index. The data were analyzed using Stata14 software.

Results: Of the 316 articles selected in the initial search, 3 articles the inclusion criteria and were used for the meta-analysis. A total of 274 firefighters were studied. The prevalence of PTSD was 23.17% among Iranian firefighters (I² = 92.4%, 95% CI = 6.71-39.62, p < 0.001).

Conclusion: The prevalence of PTSD is among Iranian firefighters relatively high and has been on the rise over the recent years.

Trauma and work factors as predictors of firefighters' psychiatric distress

BACKGROUND

Studies into the mental health of firefighters have primarily focussed on individual factors (e.g. biological and psychological factors). Little is known about how exposure to traumatic events and psychosocial and organizational work factors influence firefighters' mental health despite the evidence that these are important for employee health.

AIMS

To study job demands, job control, social support and operational trauma as predictors of firefighters' psychiatric morbidity, and whether job control and social support moderate these relationships.

METHODS

Participants were drawn from a longitudinal cohort study of firefighters in Brazil. Portuguese-language variants of the Self-Report Questionnaire (SRQ-20) and Traumatic Events List for Emergency Professionals measured psychiatric morbidity and exposure to traumatic events. Job demands, job control and social support were measured by the Job Stress Scale. Hierarchical regressions were run controlling for socio-demographics and previous psychiatric morbidity. Subsequent regression steps first included the proposed predictors followed by their interactions.

RESULTS

Thirteen per cent of the sample (n = 40/312) met the caseness criteria indicating psychiatric morbidity. Operational trauma, job demands, job control and social support predicted psychiatric morbidity. Both job control and social support functioned as moderators and where these moderators were high, the job demands and psychiatric morbidity relationships were weaker.

CONCLUSIONS

These findings show that psychosocial factors and operational trauma predict firefighters' psychiatric morbidity. Crucially, the results that improving social support and job control could mitigate the detrimental influence of job demands highlight the need for more research and practice towards organizational-level interventions.

A double-hit of stress and low-grade inflammation on functional brain network mediates posttraumatic stress symptoms

Growing evidence indicates a reciprocal relationship between low-grade systemic inflammation and stress exposure towards increased vulnerability to neuropsychiatric disorders, including posttraumatic stress disorder (PTSD). However, the neural correlates of this reciprocity and their influence on the subsequent development of PTSD are largely unknown. Here we investigated alterations in functional connectivity among brain networks related to low-grade inflammation and stress exposure using two large independent data sets. Functional couplings among the higher-order cognitive network system including the salience, default mode, and central executive networks were reduced in association with low-grade inflammation and stress exposure. This reduced functional coupling may also be related to subsequent posttraumatic stress symptom severity. The current findings propose functional couplings among the higher-order cognitive network system as neural correlates of low-grade inflammation and stress exposure, and suggest that low-grade inflammation, alongside with stress, may render individuals more vulnerable to PTSD.

The prevalence and clinical impairment of subthreshold PTSD using DSM-5 criteria in a national sample of Korean firefighters

BACKGROUND

Firefighters are at high risk for subthreshold and full-threshold posttraumatic stress disorder (PTSD) due to their frequent exposure to various traumatic events. Although individuals with subthreshold PTSD have increased impairment, often needing treatment, the rates of subthreshold PTSD in firefighters remain unknown. Moreover, there is currently no consensus regarding the definition of subthreshold PTSD. The purpose of this study was to investigate the rates and clinical impairment of subthreshold PTSD according to various definitions in a national sample of firefighters.

METHODS

A total of 45,698 Korean firefighters completed self-reported questionnaires to assess the severity of PTSD symptoms, suicidal behavior, depression, alcohol use problems, and PTS-related functional impairment. Six different definitions used in the literature were used to calculate the prevalence rate of subthreshold PTSD. Multivariable linear regression and analysis of variance were performed to identify the relationship of subthreshold PTSD with suicidal behavior, depression, alcohol use problems, and PTS-related functional impairment.

RESULTS

The rate of full-threshold PTSD was 2.63%, and the rate of subthreshold PTSD ranged from 1.79% to 17.98%. The individuals with subthreshold PTSD most commonly failed the D criteria, which included negative alterations in cognition and mood. Regardless of the definition used, subthreshold PTSD was found to be associated with increased suicidal behavior, depression, alcohol use problems, and functional impairment.

CONCLUSIONS

Subthreshold PTSD appears to be equal to or more frequent than full-threshold PTSD in Korean firefighters and associated with various negative clinical outcomes. Further effort to detect and treat subthreshold PTSD in firefighters may be essential.

Timing in drug absorption and disposition: The past, present, and future of chronopharmacokinetics

The importance of drug dosing time in pharmacokinetics, pharmacodynamics, and toxicity is receiving increasing attention from the scientific community. In spite of mounting evidence that circadian oscillations affect drug absorption, distribution, metabolism, and excretion (ADME), there remain many unanswered questions in this field and, occasionally, conflicting experimental results. Such data arise not only from translational difficulties caused by interspecies differences but also from variability in study design and a lack of understanding of how the circadian clock affects physiological factors that strongly influence ADME, namely, the expression and activity of drug transporters. Hence, the main goal of this review is to provide an updated analysis of the role of the circadian rhythm in drug absorption, distribution across blood-tissue barriers, metabolism in hepatic and extra-hepatic tissues, and hepatobiliary and renal excretion. It is expected that the research suggestions proposed here will contribute to a tissue-targeted and time-targeted pharmacotherapy.

A Relational Model for Stress: A Systematic Review of the Risk and Protective Factors for Stress-Related Diseases in Firefighters

Firefighters are considered a high-risk group for the development of PTSD and other stress-related diseases. More than the exposure to potentially traumatic events, personal and occupational characteristics have been pointed out as interfering in the perception of stress, which may lead to the emergence of mental and physical symptoms. This study aimed to analyze the relationship between the main factors that contribute to stress-related diseases in firefighters. A systematic review was conducted in order to identify original articles focusing on risk and protective factors for stress in this population. Personality traits, training, experience in extreme situations and social and organizational support influence the perception of stress and, consequently, the choice of coping strategies, which may protect against or potentiate the stress reactions. The findings of this study allow us to draw a relational model that represents the dynamics among the factors related to stress in firefighters. The development of PTSD and other stress-related diseases depends on a host of pre-trauma and post-trauma factors and, although training is an important protective factor, being prepared to face extreme situations does not mean being immune to traumatic stress.

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.

Barriers and Facilitators to Seeking Mental Health Care Among First Responders: "Removing the Darkness"

BACKGROUND: First responders (FRs) are at significant risk for developing mental health (MH) problems due to the nature, frequency, and intensity of duty-related traumatic exposure. However, their culture strongly esteems strength and self-reliance, which often inhibits them from seeking MH care. AIMS: This study explored factors that influenced FRs' perceptions of MH problems and engagement in MH services. METHODS: A community-based approach and individual ethnographic qualitative interviews were used. Recruitment of a convenience sample of firefighters and emergency medical technicians/paramedics from across Arkansas was facilitated by our community partners. Interviews were analyzed using content analysis and constant comparison. RESULTS: Analysis generated three broad factors that influenced FRs' perception of MH problems and engagement in MH services: (a) Knowledge, (b) Barriers to help-seeking, and (c) Facilitators to help-seeking. Knowledge was an overarching factor that encompassed barriers and facilitators: A lack of knowledge was a barrier to help-seeking but increased knowledge served as a facilitator. Barriers included five subthemes: Can't show weakness, Fear of confidentiality breech, Therapist: negative experience, Lack of access and availability, and Family burden. Facilitators included five subthemes: Realizing "I'm not alone," Buy-in, Therapist: positive experience, Problems got too bad, and Recommendations. CONCLUSIONS: Findings provide unique perspectives from FRs about how to best address their MH needs. First responders, as well as mental health care providers, need a more thorough understanding of these issues in order to mitigate barriers and facilitate help-seeking. As advocates, educators, and health care providers, psychiatric nurses are well-positioned to care for this at-risk population.

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.

Overview of Stigma against Psychiatric Illnesses and Advancements of Anti-Stigma Activities in Six Asian Societies

Background: In psychiatry, stigma is an attitude of disapproval towards people with mental illnesses. Psychiatric disorders are common in Asia but some Asians receive inadequate treatment. Previous review found that Asians with mental illness were perceived to be dangerous and aggressive. There is a need for renewed efforts to understand stigma and strategies which can effectively reduce stigma in specific Asian societies. The objective of this systematic review was to provide an up-to-date overview of existing research and status on stigma experienced by psychiatric patients and anti-stigma campaigns in China, Hong Kong, Japan, Singapore, Korea, and Thailand. Methods: A systematic literature search was conducted in the following databases, including PubMed, PsycINFO, Embase, Web of Science, and local databases. Studies published in English and the official language of included countries/territories were considered for inclusion in the systematic review. Any article on stigma related to any form of psychiatric illness in the six Asian societies was included. Results: One hundred and twenty-three articles were included for this systematic review. This review has six major findings. Firstly, Asians with mental illnesses were considered as dangerous and aggressive, especially patients suffering from schizophrenia and bipolar disorder; second, psychiatric illnesses in Asian societies were less socially-acceptable and were viewed as being personal weaknesses; third, stigma experienced by family members was pervasive and this is known as family stigma; fourth, this systemic review reported more initiatives to handle stigma in Asian societies than a decade ago; fifth, there have been initiatives to treat psychiatric patients in the community; and sixth, the role of supernatural and religious approaches to psychiatric illness was not prevailing. Conclusion: This systematic review provides an overview of the available scientific evidence that points to areas of needed intervention to reduce and ultimately eliminate inequities in mental health in Asia.

Qualitative Assessment of Barriers and Ideal Wellness Programming Among Rural Firefighters

OBJECTIVE

The purpose of this study was to determine and assess the perceived physical and psychosocial barriers to, and the constitution of, ideal health and wellness programming among rural firefighters.

METHODS

Open-ended, semi-structured interviews were conducted and recorded on 40 rural, structural firefighters. Responses to each question were qualitatively analyzed to determine themes.

RESULTS

Several themes emerged in regards to the physical and psychosocial stressors of the profession. Three themes emerged relating to the self-perceived barriers to overall health and wellness. There was also agreement in the components of an "ideal" workplace health and wellness program to help overcome perceived barriers.

CONCLUSIONS

The themes that emerged from the interviews with this population are similar to firefighters who work in a more urban area. This indicates that the stressors and barriers firefighters face may be occupation, and not location, driven.

Self-Efficacy as a Moderator between Stress and Professional Burnout in Firefighters

The purpose of the study is to analyze the importance of individual resources in firefighting, one of the highest risk professions. Firefighters from 12 different Polish provinces (N = 580; men; M (mean age) = 35.26 year, SD = 6.74) were analyzed regarding the perceived stress at work, burnout, self-efficacy, and a broad range of sociodemographic variables. The Perceived Stress Scale (PSS), the Link Burnout Questionnaire (LBQ), and the General Self-Efficacy Scale (GSES) were used in the study. To explore the relationships between work-related stress, burnout, and self-efficacy, separate regression models for each burnout dimension were analyzed. The results revealed that self-efficacy is a significant moderator that changes the direction and strength of the relationships between perceived stress and psychophysical exhaustion, sense of professional inefficacy, and disillusion. However, self-efficacy did not moderate the relationship between stress and lack of engagement in relationships (relationship deterioration). The results indicate that self-efficacy in firefighters is a crucial personal resource that buffers the impact of perceived stress on most burnout symptoms. It may be concluded that in high risk professions, special attention should be paid to developing self-efficacy as an important part of burnout prevention programs, pro-health activities, and psychoeducation.

Relationship between ways of coping and posttraumatic stress symptoms in firefighters compared to the general population in South Korea

Professional firefighters frequently encounter stressful events in the line of duty, which may lead to the development of posttraumatic stress symptoms (PTSS). However, it remains unclear how PTSS relates to ways of coping in this population. We evaluated the differences in ways of coping between firefighters and the general population, and we determined the relationship between ways of coping and PTSS in both groups. Professional firefighters (N = 212) and adults from the general population (N = 500) completed measures of potentially traumatic events (PTEs), the Ways of Coping Checklist, the Beck Depression Inventory, the Childhood Trauma Questionnaire. Participants who reported experiencing at least one PTE also completed the Impact of Events Scale-Revised to assess PTSS severity. Firefighters showed greater use of problem-focused coping, seeking social support, and wishful thinking than did the general population. In the firefighters group only, there were negative correlations between PTSS and problem-focused coping and seeking social support; however, the opposite was found in the general population. This study identified the unique relationship between ways of coping and PTSS in professional firefighters. Our findings highlighted that active coping, including problem-focused and seeking social support, might play a key role in alleviating firefighters' post-traumatic stress reactions.

Alcohol use disorders and insomnia mediate the association between PTSD symptoms and suicidal ideation in Korean firefighters

BACKGROUND

There has been a strong association between posttraumatic stress disorder (PTSD) and suicidal ideation, which are both major mental health concerns in firefighters. Alcohol use disorders (AUDs) and insomnia are linked with both PTSD and suicidal ideation, but no studies have examined whether the relationship between PTSD and suicidal ideation can be explained by AUDs and insomnia. The purpose of this study was to investigate the mediating role of AUDs and insomnia in the relationship between PTSD symptoms and suicidal ideation.

METHODS

A total of 7190 Korean firefighters filled out self-reported questionnaires to assess the number of exposure to incident stressors and the severity of PTSD symptoms, suicidal ideation, AUDs, and insomnia. Hierarchical multivariable linear regression analyses were performed to identify the relationship of AUDs and insomnia with suicidal ideation. Path analyses were applied to investigate the mediation effects of AUDs and insomnia on the relationship between PTSD symptoms and suicidal ideation.

RESULTS

AUDs and insomnia showed significant associations with suicidal ideation, even after adjusting for demographic factors, number of traumatic events, and PTSD symptoms. The relationship between PTSD symptoms and suicidal ideation was partially mediated by AUDs and insomnia. AUDs also had both direct and indirect effects on suicidal ideation, with the indirect effect mediated by insomnia.

CONCLUSIONS

We presented a model in which AUDs and insomnia mediate the relationship between PTSD symptoms and suicidal ideation in firefighters. Efforts to treat AUDs and alleviate insomnia could be beneficial in minimizing suicidal ideation in firefighters.