Suicides Among First Responders: A Call to Action

Posted on by Hope M. Tiesman, PhD; Katherine L. Elkins, MPH; Melissa Brown, DrPH; Suzanne Marsh, MPA; and Leslie M. Carson, MPH, MSW

 

The recent Surgeon General’s “Call to Action to Implement the National Strategy for Suicide Prevention” highlighted suicides as a significant public health problem. In 2019, there were 47,500 suicide fatalities in the U.S. and an estimated 1.4 million suicide attempts[1]. The causes of suicide are complex, with many personal, socio-demographic, medical, and economic factors playing a role. One potential risk factor is occupation and several occupations appear to be at higher risk for suicide, including first responders[2].

First responders, including law enforcement officers, firefighters, emergency medical services (EMS) clinicians, and public safety telecommunicators, are crucial to ensuring public safety and health. First responders may be at elevated risk for suicide because of the environments in which they work, their culture, and stress, both occupational and personal. This stress can be acute (associated with a specific incident) or chronic (an accumulation of day-to-day stress). Occupational stress in first responders is associated with increased risk of mental health issues, including hopelessness, anxiety, depression, post-traumatic stress, as well as suicidal behaviors such as suicidal ideation (thinking about or planning suicide) and attempts[3]. Even during routine shifts, first responders can experience stress due to the uncertainty in each situation. During emergencies, disasters, pandemics, and other crises, stress among first responders can be magnified. Relationship problems have also been linked to a large proportion of suicides among the general population (42%)[4]. Because first responders can have challenging work schedules and extreme family-work demands, stress caused by relationship problems may also be magnified in this worker group.

Law enforcement officers and firefighters are more likely to die by suicide than in the line of duty[5]. Furthermore, EMS providers are 1.39 times more likely to die by suicide than the public [6]. Studies have found that between 17% and 24% of public safety telecommunicators have symptoms of post-traumatic stress disorder (PTSD) and 24% have symptoms of depression [7]. While telecommunicators are often the very first responders engaged with those on scene, research on their suicide risk and mental health has lagged.

Even given the high number of suicides, these deaths among first responders are likely underreported. There are insufficient data on suicides and mental health issues among these workers. Many first responders may consider stress to be ‘part of the job’ and feel that they cannot or should not talk about traumatic events and other occupational stressors. Perceived stigma around mental health problems or concerns over impact on employment (i.e. being labeled “unfit” for duty) may lead first responders to not report suicidal thoughts. Additionally, occupational data may be incomplete or difficult to capture for first responders, who often have multiple jobs and/or work in a volunteer capacity. More complete data are needed to identify risk and protective factors and to design evidence-based suicide prevention programs for first responders. In addition, prevention programs should reflect the differences among first responder groups and be tailored to each worker population.

What is Being Done to Prevent Suicides Among First Responders

There are several research activities to better understand and prevent suicides among first responders. As a first step, an inter-agency team of researchers from the National Highway Traffic Safety Administration (NHTSA), and the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control (NCIPC) and the National Institute for Occupational Safety and Health (NIOSH) is analyzing suicides among first responders using the most recent three years of National Violent Death Reporting System (NVDRS) data available. The NVDRS is the only state-based surveillance system that collects data on all types of violent deaths – including homicides and suicides. This analysis will describe the circumstances of suicides among first responders. While current NVDRS data can provide a basic understanding of first responder suicides, there are many missing data elements still needed to complete our understanding of these suicides.

To address this gap in data, in 2020 the U.S. House and Senate approved funding for the Helping Emergency Responders Overcome (HERO) Act. This legislation directs the Centers for Disease Control and Prevention (CDC) to create a Public Safety Officer Suicide Reporting System to increase our knowledge of these events. The module will build upon elements collected as part of the current NVDRS infrastructure from the required source documents (death certificates, coroner/medical examiner reports, law enforcement reports) and will include information specific to the first responder community. These data will provide opportunities to better understand suicide fatalities and the circumstances around those fatalities among first responders.

Challenges and Successes

While enhancing data collection is an important step, we must recognize that many challenges are present for suicide prevention within these occupations. For example, there are few evidence-based interventions for first responders. Over the years there has been increased demand for interventions, yet most that are currently available have not been thoroughly evaluated. The military has conducted extensive resilience training and many first responder organizations are adapting this type of training for their populations, but without data, it is difficult to evaluate its impact.

Another challenge is the limited culturally competent mental health resources for first responder’s mental health needs. Often, first responders are sent to general mental health practitioners who may not understand the unique demands faced by first responders or the cultures in which they operate. While they may meet the needs of many clients, general practitioners may not understand what first responders experience on the job or be able to relate to them in a culturally competent manner. For many first responders, the transition from being a provider to client or patient is not an easy one. When a first responder finally seeks treatment, it can be devastating to encounter an ill-prepared provider and may result in reluctance to seek further help.

It is also important to highlight effective approaches to improving first responders’ mental health while noting that data on the effectiveness of these approaches with first responder groups is limited. One successful approach has been the use of peer-to-peer counseling and peer teams. Sometimes having peers who model healthy behaviors can assist in linking first responders in need of support to additional resources.

Another successful approach has been the use of formal and informal post event decompression sessions. These meetings are sometimes called a hot wash, debrief, or lessons learned. Building a routine practice to discuss what went well, how the response could have been improved, and any other issues after each call can also set the stage for these discussions to become routine and provide opportunities for responder decompression. While more casual meetings are not the same as more formal Critical Incident Stress Debriefings or post-event decompressions, any type of post-event debrief could help normalize discussions about mental health and suicide within first responder groups.

We would love to hear from you. If you are a first responder who has sought mental health services or been involved in developing interventions for suicide prevention, let us know in the comment section below what you thought was or was not helpful. Have you used peer-to-peer counseling? What would you recommend? To protect your privacy we will not post last names or e-mail addresses.

If you or anyone you know needs help, contact the National Suicide Prevention Lifeline: 1-800-273-TALK (1-800-273-8255). This is free and confidential. You will be connected to a counselor in your area. For more information, visit the National Suicide Prevention Lifeline website.

 

Hope M. Tiesman, PhD, is a research epidemiologist in the NIOSH Division of Safety Research.

Katherine L. Elkins, MPH, is an EMS/911 Specialist in the NHTSA Office of Emergency Medical Services.

Melissa Brown, DrPH, is a Behavioral Scientist in the NCIPC Division of Injury Prevention.

Suzanne Marsh, MPA, is a Team Lead in the NIOSH Division of Safety Research.

Leslie M. Carson, MPH, MSW, is a highway safety specialist in the NHTSA Office of Impaired Driving and Occupant Protection.

 

References

[1] Stone DM, Jones CM, Mack KA. Changes in Suicide Rates — United States, 2018–2019. MMWR Morb Mortal Wkly Rep 2021;70:261–268

[2] (SAMHSA. May 2018. Disaster Technical Assistance Center Supplemental Research Bulletin First Responders: Behavioral Health Concerns, Emergency Response, and Trauma)

[3] SAMHSA. May 2018. Disaster Technical Assistance Center Supplemental Research Bulletin First Responders: Behavioral Health Concerns, Emergency Response, and Trauma.)

[4] Petrosky E, Ertl A, Sheats KJ, Wilson R, Betz CJ, Blair JM. Surveillance for Violent Deaths — National Violent Death Reporting System, 34 States, Four California Counties, the District of Columbia, and Puerto Rico, 2017. MMWR Surveill Summ 2020;69(No. SS-8):1–37

[5] https://rudermanfoundation.org/white_papers/police-officers-and-firefighters-are-more-likely-to-die-by-suicide-than-in-line-of-duty/.

[6] https://www.tandfonline.com/doi/full/10.1080/10903127.2018.1514090

[7] Lilly, MM & Pierce, H. 2013. PTSD and depressive symptoms in 911 telecommunicators: the role of peritraumatic distress and world assumptions in predicting risk. Psychological Trauma: Theory, Research, Practice, and Policy, 5(2):135-41)

Posted on by Hope M. Tiesman, PhD; Katherine L. Elkins, MPH; Melissa Brown, DrPH; Suzanne Marsh, MPA; and Leslie M. Carson, MPH, MSW

22 comments on “Suicides Among First Responders: A Call to Action”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    Unfortunately this happens more often than people think. On April 1 of this year I was driving across the Pell bridge in Newport Rhode Island. I came across a vehicle with his hazards on in the right hand lane. As I passed by a gentleman get out of the passenger side of the vehicle stepped over the railing and jumped. And associate of mine Whose husband responded to the call that I placed 911 informed me that the gentleman was a police officer.

    “1.39 times more likely to die by suicide than the public” is that statistically significant? What is the comparison with similar cohort of say relatively young males? The risk in this kind of analysis is that it might actually induce suicides in susceptible individuals.

    The finding reported for EMTs was statistically significant even after adjusting for gender, age, race, and ethnicity (Mortality Odds Ratio =1.39; 95%CI=1.06-1.82). The comparison group for this study was non-EMTs in the state of Arizona. The study is included in the reference section and is only one such study showing an increase in suicides among first responders.

    It is a common myth that talking about suicide will encourage other suicides. There is stigma associated with suicide and many people are afraid to talk about it. Talking about suicide reduces this stigma and also allows individuals to seek help and share their story with others. See the WHO’s suicide myths doc and “Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?” for more information.

    Counseling Cops: what clinicians need to know (Guilford Press) is a resource to aid clinicians, chaplains and peer support staff become culturally competent. Written by experienced police psychologists , two of whom are retired cops.

    Thanks for posting this and helping to raise awareness! We at the Virginia Office of EMS have been proactively trying to address this issue. We completed an awareness campaign “Make the Call” in 2019 and also conducted a statewide survey on EMS provider mental health in 2020. We also have consolidated a bunch of resources about provider mental health and resiliency on our website. You can check out these resources at https://www.vdh.virginia.gov/emergency-medical-services/healthandsafety/. Feel free to reach out to us any time!

    There are some interesting points in time in this article. There is some validity but I will take hold opinion until I look into it further. Good article, thanks and I want more! Added to my Feed as well.

    I am an MPH student at Rutgers studying the relationship between police officers firing a weapon on a call and suicidality. I have also found a gap in literature surrounding intervention analysis. Interesting point about firefighters and cops having higher risk of death by suicide than by occupation. I wonder if career and volunteer firefighters have the same risk?

    Thank you for your comment. Many of the data sources we rely on for suicide information don’t delineate career from volunteer firefighters. For example, the National Violent Death Registry System is based on death certificate data. The death certificate captures “usual” industry and occupation. The discussion section of this journal article provides a good description of the limitations of using a death certificate based system and the issues surrounding industry and occupation from this particular source.

    Thank you so much for the post you do. I like your post and all you share with us is up to date and quite informative, i would like to bookmark the page so i can come here again to read you, as you have done a wonderful job.

    After 25 years of fire and ems service I hit the brick wall. Though my employer had EAP contract. The counselor and sessions helped, she stated she had no idea what I do or experience. I had to educate her as she helped me. There needs to be more resources to help 1st responders become mental professionals.

    It is absolutely critical that those attempting to assist responders have at least a basic understanding of our jobs and the related lifestyle. I was discouraged from seeking further help because our EAP was so clearly ill equipped to deal with anything close to job-specific stressors and situations, that I had doubts that anyone would be able to help. I’m a believer in the concept of peer support even if we’re not trained in the psychology needed to provide true care. Having a listener that at least knows where one is coming from is probably worth far more than having someone with a psychology degree.

    Loosely related, why does EMS not receive more training in psychological emergencies? They have always been a big portion of our calls locally but they have mushroomed over the last year. As I’m fond of saying, it’s the call type we see the most of but have the least amount of training to handle.

    Thank you for your comment. You are correct that many EAP providers lack a complete understanding of the issues faced by first responders. This presents challenges for first responders. Some additional options for first responders include: https://allclearfoundation.org/resources/first-responder/ems/ which has resources for EMS as well as other first responders. Also, see: https://www.sondermind.com/ which has a filter for emergency responders when looking for a therapist in your area. There are many organizations working to better identify mental health professionals prepared to treat first responders.

    Regarding your question about training, the NHTSA office of EMS is working on addressing this in the current revision of the educational standards which will be released soon. Thank you for the suggestion.

    Hello, my name is preston I am a former police officer. After getting out of law-enforcement I created an organization exactly as you mentioned above for peer to peer support. Our organization is going to be having seminars traveling from police departments, fire departments, and other first response facilities for the purpose of teaching pro activity about PTSD prevention. We are located in San Antonio Texas and we taking both first responders and combat veteran suffering from PTSD and effects of trauma. It is our hope that starting with Texas, critical incident stress debriefings will no longer be an option for the individual officer. This goes for all first responders. The average police officer does not know the damage he will be inflicting on his future self. Neglecting to take critical incident stressed he briefings out of a fear of being judged or just feeling macho has a greater sacrifice and they are realizing at the moment. Essentially they do not know what they don’t know. My organization will offer a consistent critical incident stress debriefing once a week after the incident to any department in need. We feel that the findings of the CDC hearing this article prove all the more that what we are doing is on the right track. Thank you for your research and putting out this article. However we are barely scratching the surface on where we could be in the future with this issue with the darkness, PTSD.

    Thanks for important information! It’s true that first responders, including law enforcement officers, firefighters, emergency medical services (EMS) clinicians, and public safety telecommunicators are constantly exposed to stressful situations while working. They constantly need to make quick decisions that have consequences. The data on suicide among law enforcement officers, EMS and firefighters shoсked me. It is right to monitor the mental health of employees and prevent possible suicide attempts. There are different therapies and ways to monitor employee mental health improvement.

    Thank you for your comment.

    I am a graduate student studying PTSD and first responders. My field is strategic communications. I believe communication is a powerful change agent in these issues. I don’t mean communications alone but paired with the psychologist’s input. I am looking at communications beyond those impacted directly by PTSD but also include public administrators, HR, and policymakers who might inadvertently add difficulties or barriers in help-seeking faced by first responders.
    I mean why would a first responder want to speak up to management and HR if they fear their career chances will be wrecked by coming forward about having mental health issues?
    Do psychologists team up with strategic communicators? If so, that’s what I want to do.

    Thank you for your comment highlighting the importance of agency policy, communication, and culture. We agree that communication is a powerful change agent and are happy to hear that you are interested in pairing your work as a strategic communicator within the field of mental health and psychology. It is important to craft the right message and make sure that all those involved in the first responder community are aware of how department policies, resources and communications impact the health and well-being of the workforce. The first responder community still struggles with stigma, fear of being deemed unfit for duty and the discomfort of being the patient as opposed to the helper. It will take significant work on all fronts to improve how we communicate about mental health and mental health treatment, stress, resilience, and substance abuse and it would be wonderful if psychologists and strategic communicators were collaborating to help first responder organizations overcome these challenges. While we haven’t specifically looked for cases where strategic communicators and psychologists team up, we do recognize that a strategic communication specialist could assist in all facets of occupational medicine for a first responder agency.

    I’ve had excellent success with my therapist/EMDR because they focus specifically on treating first responders and military folks. They are able to understand exactly where I am coming from without judgment, which I have in the past received from therapists who were poorly equipped to understand my life as a paramedic. It was indeed a fairly damaging experience for me to feel judged by a therapist who did not seem to understand the wide range of negative emotions that I felt when I was burning out and traumatized. It also helps that my therapist is very familiar with how toxic my former employer is due to how many clients they see who are former colleagues of mine: they are able to see the “big picture” of the politics there from many angles, which saves me a lot of time in session that I would ordinarily have to spend explaining a bunch of background information to any other therapist.

    Something that I would like to see studied further (in addition to everything else) is the prevalence of gaslighting, gate-keeping, and bullying in EMS departments. I ultimately left the ambulance after many years of service because I refused to put up with toxic departmental culture that only served to exacerbate my PTSD. I would very much love to share more information about my experience with you.

    Thank you for our article and resources for First Responders.

    I’m wondering if you have heard of Mental Health First Aid (MHFA)? I’m a part of a project that offers MHFA (https://www.mentalhealthfirstaid.org/) to First Responders and others. The one day training teaches laypersons how to screen and intervene when they see signs and symptoms of a mental health or substance use issues so people can get the help they need when they need it. The person trained in our program to provide first aid is not a counselor but is trained to offer information about local resources for appropriate professional and self-care help.

    MHFA is an international program that is on the SAMHSA’s list of evidence-based programs and has specific modules for EMS/Firefighters and Public Safety. MHFA is all across the country. Once we expand to Ohio and Kentucky we will be looking for FRs to teach our classes since they understand the unique culture. Thinking of the gentleman’s comment that more FRs should become mental health professionals, becoming a MHFA Instructor (https://www.mentalhealthfirstaid.org/become-an-instructor/ ) may be an opportunity for FR looking to play a bigger role in helping their peers with mental health issues. If a whole department/force was trained in MHFA, evidence shows that the stigma decreases as people feel more open to talk about it.

    Re: MHFA – can you point me to any peer review articles or data/evidence re: efficacy? I’ve looked but had no luck. Thanks in advance.

    Re: peer support teams: we’ve found resistance to providers engaging with their own agency’s peer support team. What has worked well is having another agency’s peer support team work with providers from our agency when appropriate. It helps reduce the stigma associated with reaching out for help.

Post a Comment

Your email address will not be published.

All comments posted become a part of the public domain, and users are responsible for their comments. This is a moderated site and your comments will be reviewed before they are posted. Read more about our comment policy »

Page last reviewed: April 6, 2021
Page last updated: April 6, 2021