APNA 30th Annual Conference Session 4033: October 22, 2016 - - PDF document

APNA 30th Annual Conference Session 4033: October 22, 2016 Jones 1

Assessing the Mental Health of First Responders: A Systematic Review

Sara Jones, PhD, APRN, PMHNP-BC

University of Arkansas for Medical Sciences College of Nursing

sljones@uams.edu

The speaker has no conflicts of interest to disclose.

Objectives

• Discuss duty‐related trauma exposure and risk for mental and

substance use disorders among first responders.

• Identify the prevalence of mental and substance use disorders

among first responders as presented in a systematic review.

• Understand duty‐related trauma exposure on first responders

and the implications for psychiatric nursing practice and future research. The speaker has no conflicts of interest to disclose.

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First, a little bit about me….

• Education
• Practice
• Research
• Married to a Firefighter/paramedic

I WANT TO TELL YOU LIES

“…But I have to tell it like it is, until my shift is through And then the real lies begin, when I come home to you You ask me how my day was, and I say it was just fine I hope you understand, sometimes, I have to tell you lies.”

Kal the Rebel. (n.d.) I want to tell you lies. Retrieved from http://www.geocities.ws/kaltherebel/IWantToTellYouLies.html

First Responders

• Firefighters, paramedics, & emergency medical

technicians (EMTs)

• Law enforcement personnel

– Comparatively, vast differences in training & job duties

• Dispatchers
• Healthcare providers
• Rescue workers

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Duty-related trauma exposure

• “Sentinel Events”

– Baby Jessica (1986) – September 11th

• But, many may serve an entire career without

working a sentinel event

• Approx. 50 million emergency calls annually (U.S.)
• Every dispatch has the possibility of trauma exposure

Increased risk for mental health conditions

Searching the literature

• First responders: individuals from various professions
• Large focus on the effects of specific sentinel events (i.e. 9/11)
• Primary focus is on PTSD
• Different standardized assessment measures used

How do the day‐to‐day operations & experiences that are expected & accepted as part of a their job affect first responders’ mental health?

Preferred Reporting Items for Systematic Reviews and Meta‐ analyses (PRISMA) guidelines used to identify the prevalence of mental disorders among first responders.

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• Countries: U.S. (n=13), Australia (n=4), Brazil (n=2), UK (n=2),

Germany (n=2), Canada, Netherlands, Poland, Scotland, South Africa, & Taiwan

• Firefighters (n=19)

– Volunteer (n=1), professional (n=6), and urban (n=2) firefighters.

• EMTs & paramedics (n=8)

– Ambulance workers (n=1), rural (n=1), paramedic students (n=1), and urban paramedics & paramedic students (n=1)

• Mental health concern: PTSD (n=18), depression (n=11) &

suicidality (n=4), anxiety (n=5), alcohol (n=6) and substance use (n=2), sleep disturbance (n=3), & general psychopathology (n=6)

Study Descriptions PTSD

• General populations: 8.7%

Veterans: 10‐31%

• 1996‐2000: 17‐22% (U.S. & Canada)

– Internationally: 17‐21%

• 2000‐2014 (Internationally): As low as 3.5‐7% (U.S)

– Australia: 68% moderate, 7.4% severe – Brazil: 15% met partial criteria, 5.6% met full – Scotland: 30% moderate, 30% severe

• Career vs. Volunteer (Australia, 2003)

– Significant PTSD (9.3% compared to 4.5%) – Extreme PTSD (13.3% compared 4.5%) – Severe psychological distress (17.3% compared to 7.5%)

PTSD: I ncreased Risk

Work related:

– High levels of work strain, increased hours, low sense of coherence – Age started working (younger), years of service, & rank (supervisory) – Severity of horror felt after Single Worst Incident, fatalities with children – Work vs. Home conflicts

Personal:

– Poor social support, marital status (single) – Previous psychological treatment, increased sx of depression & anxiety – Co‐occurring medical problems

Personality traits:

– High levels of denial, low levels of empathy, poor resilience – High levels of hostility & low levels of self‐efficacy before job entry

APNA 30th Annual Conference Session 4033: October 22, 2016 Jones 5

Depression & Suicidality

• General populations: 7%
• Correlation between lifetime MDD & PTSD estimated at 0.50

– Both highly associated with suicidality; co‐occurrence increases symptoms – Comorbidity varies between 21‐95%; often associated with trauma exposure

DEPRESSION

– Studies that examined both PTSD & MDD (n=4): 3‐28% – Primary focus on depression (n=2): 6.8‐11%

SUICIDE: 1/4 career & 1/5 volunteer had considered suicide (NFVC)

• Dissertation: 16 yrs (NC; n=982): 25 deaths (3x LOD deaths)
• Lifetime SI: 46.8% (U. S. 2015; n= 1025)

– Plan: 19%; Attempted: 15.5%; Non‐SI self‐injury: 16.4%

Depression: Increased Risk

• Greater than 16 years in service
• Medical health concerns
• Being a paramedic (vs. EMT)

Suicide: Increased risk

• Occupational stress, poor social support
• Lower rank, fewer years on job
• Military status
• All‐volunteer
• History of responding to suicide attempt or death

Alcohol Use

• General populations: 6.8%
• Binge drinking: more than 4 drinks (women) & 5 drinks (men) on 1
• ccasion (NIAAA, 2004): 1/6 adults binge 4x/month

In the fire service, alcohol consumption is common & heavy drinking are considered part of the culture, but there are FEW studies!

• U.S. firefighters (n=954): up to 89% reporting alcohol consumption
• Binge drinking: 33‐58% (3 studies)

– Hazardous drinking: 14% (n=112)

APNA 30th Annual Conference Session 4033: October 22, 2016 Jones 6

Sleep Disturbance

• Symptomatic of mental health conditions AND contributes to the

development of…. Difficult to assess causation

• Shift work! Sleep deprivation= less than 4‐6hr/sleep/24 hrs

– Fatigue, decreased alertness, poor concentration

4 Studies:

• Ambulance workers‐ high levels of fatigue: 10%
• Brazilian firefighters‐ sleep disturbances: 51%
• Australian, rural paramedics‐ poor sleepers: 70%
• Increased rates of Depression, SI, chronic fatigue, & AUD

Practice I mplications

#1 problem: Strong stigma, perceived possibility of confidentiality loss, & culture of self‐reliance Decreased help‐seeking

• General populations: less than 40% seek services

– Only 32‐55% receive recommended care

• Psychiatric evaluations: include inquiry about profession &

related risk factors*

• Sleep disturbances!
• Annual Physical: To include comprehensive psychiatric

evaluation

Resources

Evidence‐based, population‐specific interventions are scarce!

• Employee Assistance Programs (EAPs)
• Critical Incident Debriefing (CID): possibly increases risk
• National Fallen Firefighters Foundation: Everyone Goes Home

– Initiative 13: Psychological Support‐ shift from EAP to BHAP – STRESS FIRST AID: Peer support model

• International Association of Firefighters (IAFF)

– Behavioral Health & Suicide Awareness training

• Firefighter Behavioral Health Alliance (FFBHA; since 2010)

– 2016: 68 firefighters, 22 paramedic/EMT (2015: 130)

APNA 30th Annual Conference Session 4033: October 22, 2016 Jones 7

Research I mplications

• To reduce stigma & increase help‐seeking

behaviors

– Barriers to help‐seeking? – Community‐engagement approach?

• Tailored interventions

– Need evidence‐based models!

• Modalities used with other victims of trauma?

– Veterans, abuse victims? – TF‐CBT, EMDR References

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