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The Prevalence of Trauma-Related Symptoms in First Responders and the
Effectiveness of Current Treatment Approaches
The population term “first responders” traditionally include emergency medical
technicians, paramedics, firefighters, and police officers. Recently, there has been a
push to include 911 call operators in this population as well, but research is limited and
not included in this analysis as a result. This first responder population is exposed to
events that can cause direct or vicarious trauma on a regular basis, and although the
results of studies have varied, most research indicates that post-traumatic stress
symptoms are seen in first responders at a significantly higher rate than in the general
population (Alden et al., 2021). These symptoms often result in or are comorbid with
symptoms of depression, anxiety, and burnout. Historically, the culture of first
responders has disincentivized individuals to seek mental health care due to varying
stigma (Jones et al., 2019). The combination of increased traumatic stressors and a
culture disincentivizing help-seeking behavior has lead to some studies researching the
prevalence of suicide and suicidality in first responders. The research is somewhat
unclear but indicates first responders may be at increased risk (Stanley et al., 2015).
The organizational, personal, and cultural influences of first responder society heavily
contribute to burnout, which has been linked to many different mental health risk factors
such as feelings of hopelessness, exhaustion, and depersonalization (Mika-Lude et al.,
2023). This paper discusses the unique risk factors faced by first responders, the
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culture of stigmatizing help-seeking, and an evaluation of the effectiveness of classic
trauma therapy strategies within this population. Almost all studies indicate that more
research is needed around this population with both larger sample sizes and a more
clinical, as opposed to self-report based, approach.
First responders face a unique set of risk factors that the general population does
not encounter regularly. These include exposure to death, both risk of their own and the
death of those they seek to help, long and odd hours including overnight work, and
increased disruptions in familial and social support systems (Stanley et al., 2015).
These risk factors are thought to contribute to PTSD, depression, burnout, and
suicidality. Of note, approximately 90% of first responders self-reported they are
exposed to repeated workplace incidents that are direct threats to their lives or are
repeatedly witness to the death of others (Alden et al., 2021).
Alden et al. (2021) also noted a review that estimated the prevalence rate of
PTSD among first responders. There was high variation among PTSD prevalence rates
found among multiple studies. Police officers had rates from 0-43%, firefighters had
rates from 3.9-54%, and ambulance personnel had rates of 4-40%. Despite the variation
in prevalence rates, most research concludes that PTSD symptoms are higher in first
responders than in the general population. When the populations are combined,
prevalence rates of PTSD in first responders have been found to be as high as 32%,
which is significantly higher than the general population at 6-14% (Walker et al., 2016).
Petrie et al. (2018) conducted a meta-analysis of multiple studies that totaled
30,878 ambulance personnel. The results found that this population is under
researched. This was also shown by Stanley et al. (2015) who studied 63 articles about
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suicidality in first responders, but only 2 of those articles directly researched ambulance
personnel. Most studies of ambulance personnel and first responders have focused
primarily on PTSD. In their meta-analysis, Petrie et al. (2018) found a PTSD prevalence
rate of 11% and noted that when analyzing studies from 2000 until the present, the
prevalence rate was only 8%. The latter rate was only the result of 10 studies but may
show that PTSD rates are lowering over the past 2 decades. Ambulance personnel in
this study had a prevalence rate of 15% for both depression and anxiety, as well as a
rate of 27% for general psychological distress. The findings of higher prevalence rates
for anxiety and depression than for PTSD indicate that the research and first responder
agencies need to address these concerns in their mental health programs in addition to
the current focus on PTSD (Petrie et al., 2018).
Physiologically, Walker et al. (2016) note that recent research indicates elevated
levels of cytokines can cross the blood brain barrier. Elevated levels of pro-inflammatory
cytokines have been linked to depression. They went on to propose that chronic lowgrade inflammation, which usually involves a 2-3 times increase of pro-inflammatory
cytokines, can result from repeated occupational stressors and traumatic events like
seen in first responders. Elevated cytokine levels can also cause dysregulation in the
autonomic nervous system’s flight-fight-freeze response. Walker et al. (2016) go on to
propose ways to further research this avenue in first responders while addressing
occupational stressors like heat, smoke, sleep disturbances, exhaustion, and injury.
While no results from the proposed avenue of research have been collected yet, the
connection of occupational stressors, cytokine induced inflammation, and PTSD may be
an area of research that proves useful in the future.
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Another area where more research is needed is about burnout. Burnout has
been described as both a “protective state of apathy” and a physical and emotional
response resulting from chronic occupational stress. Burnout has been identified as a
contributing factor for feelings of hopelessness, exhaustion, depersonalization, and
reduced job satisfaction. These presenting symptoms from burnout may also be linked
to more severe mental health concerns like depression and PTSD (Mika-Lude et al.,
2023). A Polish study (Witczak-Błoszyk et al., 2022) addressed the effect of exposure to
suicide on burnout and examined the type and effectiveness of coping strategies
employed by first responders. Of the individuals studied, 98% reported work-related
exposure to suicide or suicide related events, such exposure leads to higher levels of
burnout, and the informal coping strategies self-employed by the first responders were
commonly suboptimal.
In the study by Witczak-Błoszyk et al. (2022), the coping mechanisms examined
included avoidance of thinking and/or talking about the event, focusing on the positive
benefits of their work, reframing the event as a learning experience, humor, alcohol and
drug use, and social support from family, friends, and coworkers. Coping was analyzed
using the Coping Inventory for Stressful Situations (CISS), measuring three coping
styles (task oriented, emotion oriented, and avoidance). Although task-oriented coping
was found to be the most effective style, first responders typically utilized emotion
oriented and avoidant coping styles more frequently. This may be due to only half of the
participants being willing to seek professional psychological assistance. Decreasing
stigma of help-seeking behavior and raising awareness around the more effective task-
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oriented coping skills were suggested to decrease the high levels of burnout in first
responders.
Burnout has also been linked to dehumanization (Mika-Lude et al., 2023).
Dehumanization is defined as the denial of humanity and can be used to vilify, deify, or
mechanize. First responders face dehumanization from three main areas, the public,
their organizations and companies, and themselves. The public often swings between
vilifying first responders and deifying them depending on recent events like police
brutality and national emergencies. The mechanization of first responders often comes
from their organizations and themselves. The organizations were reported by first
responders to treat people like robots or numbers (Mika-Lude et al., 2023). 69% of first
responders reported not being given enough recovery time between traumatic incidents
by their employers (Bentley et al., 2013). The link noted between dehumanization,
burnout, and suboptimal coping choices is important when considering both how to treat
first responders when they present with mental health concerns as well as in
establishing new policies and support systems to prevent burnout and post-traumatic
stress symptoms.
Most studies conducted with first responders have gathered data using a selfreport method, and the culture of first responders has stigmatized seeking mental health
care and participation in such studies. In the meta-analysis by Petrie et al. (2018), they
noted that the average response rate for self-report based studies was 57%. In the
Polish study, 24.3% of the population approached stated they were unwilling to seek
psychological help and 19.2% were unsure if they felt comfortable doing so (WitczakBloszyk et al., 2022). Jones et al. (2019) sent out an online form which got a response
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from 61 Arkansas firefighters and emergency medical personnel. Of that 61, only 32
responded after two follow up calls to schedule an interview. In the interview
participants answered questions about their mental health history, their education
surrounding mental health, access to mental health services, and barriers to helpseeking. All participants noted the need for more education and awareness around
mental health issues in first responder culture. When asked about barriers to helpseeking, the most common issues reported were pride, denial, and stigma. The stigma
often stemmed from a desire to “not show weakness” and the fear of being labeled as
“crazy”. Another notable barrier to care was the resignation that no one outside of the
first responder community, even a therapist, would be able to understand what they had
been through. Although the stigma of seeking mental health services and the culture of
self-sufficiency and perceived heroism is a strong barrier to entry, the interviewed first
responders also noted multiple facilitators to help-seeking behaviors. Most notable was
awareness that others in the field are struggling too and seeking help, which reduced
feelings of isolation around mental health concerns and increased willingness to
participate. On a less positive note, multiple participants noted that the only reason they
had engaged with mental health services in the past was that their initial concerns
became a mental health crisis (Jones et al., 2019).
When determining the course treatment should take, a provider should keep in
mind the unique set of risk factors, increased prevalence of post-traumatic symptoms,
and the cultural stigmatization of help-seeking behavior of first responders. One
question that arises is how effective are classic forms of trauma therapy in first
responder populations? Alden et al. (2021) conducted a literature review to address this
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question. They noted that a similar review from 2012 had concluded that there was not
sufficient evidence to be able to recommend any best practice treatment options
specific to the first responder population. The 2021 study found that although the
amount of research being conducted was increasing, the number and quality of the
research had not improved sufficiently to draw any conclusions related to the
recommendation of best practices for first responder trauma therapy (Alden et al.,
2021). The literature focused on trauma focused therapies targeting PTSD in three
categories: trauma-focused cognitive behavioral therapy (TF-CBT), EMDR, and brief
eclectic psychotherapy. The trends in the research indicate that all three approaches
appear to have positive effects on PTSD and depressive symptoms, and that no specific
approach was more beneficial than another (Alden et al., 2021).
A second meta-analysis of the effectiveness of psychological interventions for
PTSD in first responders was conducted with a wider range of research included. It
concluded psychological interventions are effective in treating PTSD, depression, and
anxiety (but not stress) in first responders. It also found that the use of CBT resulted in
significantly greater reductions in PTSD symptoms than other types of psychological
interventions (Alshahrani et al., 2022). Both studies found that research regarding the
effectiveness of treatment for first responders only included a small amount of research
on ambulance personnel. They note that PTSD occurs at a higher rate in ambulance
personnel than in other first responders and encourage future research to reflect this
(Alshahrani et al., 2022).
Critical incident stress debriefing (CISD) is a controversial practice where a
facilitator leads a group through their initial response to a traumatic event. The ethics of
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which have been debated due to conflicting research. Some research indicates that
CISD may be harmful to recently traumatized individuals and re-traumatize them.
Others indicate that it is beneficial in reducing the prevalence of PTSD symptoms later.
Jacobs et al. (2004) notes that findings suggest CISD can be effective in reducing the
risk of developing PTSD in first responders, but also that CISD conducted with direct
victims of the trauma is not supported by the research.
A more recent development in PTSD studies surrounding first responders is
equine-therapy as a supplement to trauma-focused psychological treatment. Nelson et
al. (2022) conducted a pilot study with 7 first responders who were suffering from
mental health issues after work-related traumatic events. The study measured anxiety,
depression, trauma-related symptoms, inflexibility, and avoidance both before and after
treatment. Although only 25% attended all 8 sessions, and only 50% attended at least 6
sessions, statistically significant reductions were found in both depressive and traumarelated symptoms. Although this was only a pilot study, the results for equine-therapy
use with first responders are promising (Nelson et al., 2022).
First responders fill a critical role in society. These individuals respond to
emergency calls, work odd and long hours, and are surrounded by a culture that
promotes self-sufficiency and discourages help-seeking behavior. These circumstances
have caused first responders to be exposed to more traumatic scenarios than most of
the general population. They also suffer from PTSD at a significantly higher rate than
the general population. Various therapeutic strategies and programs have been used to
treat first responders with mental health concerns. Although results are mixed, CBT may
be the most widely appropriate treatment for first responders with PTSD. Future
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research with this population would be helpful in improving the high prevalence of PTSD
and other mental health concerns. Petrie et al. (2018) notes that PTSD prevalence rates
in ambulance personnel are shown by some studies to be decreasing over the past two
decades. They suggest three hypotheses to why this was found. First, study
methodology changed over time with the use of different scales or with the ability to
access larger more representative sampling. Second, under-reporting of PTSD may
have increased over time due to stigma or fear of organizational consequences of
admitting mental health issues, leading to lower self-report rates of PTSD. Third, there
has been a real change in PTSD prevalence rates over time due to an increase of
awareness of mental health concerns in the industry and the introduction of a variety of
mental health initiatives. This seeming decline in PTSD among ambulance personnel is
hopeful, but more, and more focused, research is needed to improve treatment
efficiency for first responders and attempt.
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