Combating Poor Mental Health in Emergency Responders

Krisha A. Gupta DO, MPH | kg1453@mynsu.nova.edu

INTRODUCTION

Suicide rates are alarmingly higher among emergency responders than the public, with 30% of first responders developing behavioral health conditions compared to 20% in the general population.1,2 H.R. 1480-Helping Emergency Responders Overcome (HERO) Act was introduced to combat mental health concerns among emergency responders by improving detection, prevention, and treatment of mental health concerns in this population3. Having passed the House, this bill is under consideration within the Senate.

This policy issue is important to osteopathic family physicians as our patients include emergency responders, and we practice holistic medicine. Thus, we play a significant role in detecting, treating, and advocating for changes in current mental health practices.

BACKGROUND AND SIGNIFICANCE

Among first responders, the career prevalence of suicidal ideation, plans, and attempts are 46.8%, 19.2%, 15.5%, respectively; this differs from the lifetime prevalence of suicidal ideation, plans, and attempts in the general population, which are 13.5%, 3.9%, and 4.6%, respectively.4 Female emergency responders have the second highest rate of suicide, and male emergency responders have the sixth highest rate of suicide.5 Firefighters report the highest level of post-traumatic stress disorder (PTSD) symptoms among emergency responders at 17–22%.6

Despite their work-related stress, emergency responders often under-report mental health challenges, fearing job discrimination and negative performance evaluations by peers and supervisors.7 Only 40% of suicides committed by firefighters and police officers are reported.8 When adjusted for under-reporting, firefighters and police officers are twice as likely to die from suicide than in the line of duty. Stigma, prioritizing bravery and toughness, lack of media coverage of emergency responder suicides, and lack of suicide prevention training are documented barriers to emergency responders accessing mental healthcare.8 The HERO Aact seeks to address suicidality, poor reliability of reported suicide rates, and lack of guidelines for suicide prevention programs amongst emergency responders.3

OUTCOMES AND STAKEHOLDERS

The HERO Act intends to improve mental health and decrease suicidality among emergency responders through improved detection, prevention, and treatment.3 It will fund efforts to establish evidence-based best practices for identifying, treating, and preventing PTSD and co-occurring disorders in emergency responders.3 It will provide grants to execute behavioral health programs within emergency responder departments, and it will produce emergency responder-specific mental health treatment educational materials for mental healthcare professional.3

The HERO Act is supported by the International Association of Fire Fighters, the National Volunteer Fire Council, the American Foundation of Suicide Prevention, the International Association of Fire Chiefs, the American Association of Suicidology, and the Firefighter Behavioral Health Alliance.9

ALTERNATIVE STRATEGIES

Alternatives to the strategies proposed in the HERO Act include resiliency training and Critical Incident Stress Debriefing (CISD).10 Many emergency responder training programs emphasize resilience training to improve mental health.11 Among emergency responders, high baseline resilience is correlated with better quality of life and better coping with PTSD.12 The Substance Abuse and Mental Health Services Administration recommends self-efficacy and resilience training for emergency responders before they go into the field to improve their mental health and reduce adverse outcomes.13

CISD is a technique wherein responders disclose traumatic experiences in group settings with trained facilitators. It intends to promote community in responders with shared trauma, while also allowing identification of responders needing further counseling.13 Responders have described CISD as “intrusive,” causing further distress and worse feelings following these discussions.14

APPLICATIONS FOR OSTEOPATHIC FAMILY MEDICINE

The HERO Act is important to the field of family medicine, as such providers are the first line for many patients with mental health concerns. Eighty percent (80%) of individuals who completed suicide had contacted family medicine providers within one year of suicide, and 44% had contacted family medicine providers within one month of suicide.15 Only 31% contacted mental healthcare providers in the year prior to completing suicide.15Efforts by family medicine providers to manage suicide concerns include practitioner education programs, suicide risk and mood disturbance screenings, and management of depression symptoms and suicide risk.16

A pilot study of osteopathic manipulative treatment (OMT) on emergency responders with techniques including rib raising, sacral rocking, suboccipital inhibition, and CV4 Stillpoint induction, successfully improved psychological self-assessment scores and created alterations in biomarkers (IL-6, IL-2, hCRP, and cortisol) associated with stress, anxiety, and depression when compared to sham treatment.17

Osteopathic physicians may perform the OMT techniques mentioned above on their first responder patients, who report to their clinics with symptoms of stress, anxiety, and depression. Further studies conducted on OMT techniques for the first- responder population could further validate the usefulness of OMT in this population. This would add to evidence-based research recommendations to use in practice following implementation of the HERO Act.

Doctors of osteopathic medicine physicians, OFP, and osteopathic associations can advocate for the HERO Act by issuing public statements in support of the HERO Act and by individually contacting their senators, encouraging them to vote in favor of the HERO Act.

RECOMMENDATIONS

Emergency responders are essential members of our communities. Tragically, they are at “significant risk for developing mental health problems due to the nature, frequency, and intensity of duty-related traumatic exposure”.18 Given the prevalence of emergency responders cared for by osteopathic family physicians, it would be valuable for our profession to contribute to discussions surrounding this legislation. Furthermore, we recommend osteopathic family physicians advocate for OMT techniques, proven successful in treating emergency responders, be considered as part of the evidence-based best practices used in creating guidelines and programs under the HERO Act.

CONCLUSION

Compared with the general population, emergency responders are at increased risk for death by suicide.1 While strategies exist to reduce mental health challenges among emergency responders, many are not backed by evidence.11 The HERO Act aims to negate this discrepancy by providing resources to those working to address this problem alongside emergency responders, like family physicians who are in the position to identify, prevent, and treat mental health disorders in emergency responders.3 Osteopathic family physicians are trained with an emphasis on holistic medicine and caring for the mind, body, and spirit of their patients. They are uniquely qualified to advocate for and serve emergency responders with mental health concerns predisposing to suicidality.

REFERENCES

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2. Abbot C, Barber E, Burke B, Harvey J, Newland C, Rose M, Young A. What’s killing our medics? Reviving Responders. 2015.

3. H.R.1480 - 117th Congress (2021-2022): HERO Act. (2021, May 13). http://www.congress.gov/.

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5. National Action Alliance for Suicide Prevention. Public safety-Action Alliance website. https://theactionalliance.org/communities/workplace/ public-safety. Updated 2021. Accessed February 25, 2022.

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9. Representative Ami Bera, M.D. (2020). Rep. Bera’s Helping Emergency Responders Overcome (HERO) Act Passed by Energy and Commerce Committee. [Press Release]. https://bera.house.gov/media-center/press- releases/rep-bera-s-helping-emergency-responders-overcome-hero-act- passed-by. Published July 15, 2020. Accessed February 25, 2022.

10. BC First Responders Mental Health Committee. Supporting Mental Health in First Responders: Recommended Practices. https://bcfirstrespondersmentalhealth.com/wp-contentuploads/2017/05/Recommended-Practices-for-Supporting-Mental- Health-in-First-Responders-191029.pdf. Published October 28, 2019. Accessed February 25, 2022.

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13. Substance Abuse and Mental Health Services Administration. First Responders: Behavioral Health Concerns, Emergency Response, and Trauma. https://www.hsdl.org/?view&did=813843. Published May 2018. Accessed Februrary 25, 2022.

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15. Stene-Larsen K, Reneflot A. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health. 2019;47(1):9-17. doi:10.1177/1403494817746274

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17. Abraham C, Sloan SNB, Coker C, et al. Osteopathic manipulative treatment as an intervention to reduce stress, anxiety, and depression in first responders: a pilot study.. Mo Med. 2021;118(5):435-441.

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