Differences in psychiatric symptoms and barriers to mental health care between volunteer and career firefighters
Introduction
Each year in the U.S., over 1,000,000 firefighters risk their lives by responding to high-risk emergencies (Haynes and Stein, 2016). The nature of the firefighter vocation (e.g., repeated exposure to painful and provocative experiences, erratic sleep schedules) likely poses a significant risk to firefighters’ mental health. Indeed, past research has revealed elevated rates of a myriad of mental health problems among firefighters, including depression (Hom et al., 2016c), substance abuse (Carey et al., 2011), sleep disturbances (de Barros et al., 2012, Hom et al., 2016c), and posttraumatic stress symptoms (PTSS) and posttraumatic disorder (PTSD; Heinrichs et al., 2005). Emerging research also suggests that firefighters may be at elevated risk for suicidal thoughts and behaviors (Chu et al., 2016, Henderson et al., 2016, Kimbrel et al., 2016, Stanley et al., 2016, Stanley et al., 2015), likely in part due to repeated exposures to traumatic events (Boffa et al., 2017), including the suicide attempt of another person (Kimbrel et al., 2016). Given the scope of psychiatric symptoms that have been found to be elevated among firefighters, empirical efforts to examine firefighter-specific characteristics that may potentiate risk is warranted. In so doing, specific at-risk sub-populations can then be identified, allowing for targeted prevention and intervention efforts. Indeed, among the highest research priorities identified by the 2015 National Fire Service Research Agenda is that which aids in “identifying those individuals within the fire service who are at a higher risk for specific occupational injury/illness/disease” (National Fallen Firefighters Foundation, 2016a).
One major distinction between firefighters is whether they are serving in career versus volunteer departments. Of note, most U.S. firefighters are volunteers (69%), of whom the vast majority serve communities of fewer than 25,000 people (95%; Haynes and Stein, 2016). Moreover, of the estimated 29,980 fire departments in the U.S. in 2014, approximately 19,915 (66.4%) were designated as volunteer-only. Although the nature of volunteer and career firefighting is in many ways similar, there are important differences, among them being cumulative time exposed to potentially traumatic events, competing demands (e.g., volunteers often have a separate, paid job), and areas served. Indeed, it is possible that these factors create stress vulnerabilities that contribute to the development and/or exacerbation of psychiatric conditions. Moreover, it may be that organizational factors (e.g., more systematic and stringent recruitment and screening process within career compared to volunteer departments) may account for differences in psychiatric symptoms between these two fire service sectors. Potentially greater availability of mental health resources (e.g., access to employee assistance programs [EAPs], formal peer support training) among career compared to volunteer fire departments may also contribute to differences in psychiatric symptoms between volunteer and career firefighters.
Despite these conjectures, to our knowledge, no study has empirically examined differences in psychiatric symptoms between volunteer and career firefighters. Research examining mental health among firefighters has repeatedly relied on samples of career-only (Carey et al., 2011, Heinrichs et al., 2005) or volunteer-only (Bryant and Harvey, 1996) firefighters, or studies are ambiguous in this regard. We are only aware of two studies that have explicitly examined descriptive differences in mental health among a hybrid sample of firefighters (i.e., the sample included both career and volunteer firefighters; Haddock et al., 2012; Stanley et al., 2015). In a study of alcohol use among a sample of 656 firefighters (n=459 career, n=197 volunteer), 58% of career and 40% of volunteer firefighters reported heavy drinking; however, data were not presented on the statistical significance of this difference (Haddock et al., 2012). Additionally, in a large study of 1,027 firefighters, volunteer firefighters were significantly more likely than career firefighters to report career suicide plans and attempts in uncontrolled analyses (Stanley et al., 2015). These findings suggest that there may be meaningful differences between career and volunteer firefighters, underscoring these distinctions as an important area for future inquiry. However, these past examinations are limited in scope and do not systematically examine within-fire service differences in symptom severity across other domains (e.g., depression, insomnia, and PTSD). Moreover, although mental health services serve as a conduit to symptom reduction, no data exist on differential barriers to mental health service use among firefighters serving in volunteer versus career departments.
The purpose of this study was to describe differences in psychiatric symptoms and barriers to mental health care between current U.S. firefighters in volunteer-only and career-only departments. Moreover, in exploratory mediation analyses, we aimed to determine if greater structural barriers to mental health care (e.g., cost, availability of resources) significantly accounted for the relationship between firefighter type (i.e., volunteer versus career) and psychiatric symptom levels. Given past research demonstrating elevated rates of specific psychiatric symptoms among firefighters generally, the following symptom domains were assessed: depression (Carey et al., 2011, Hom et al., 2016c), problematic alcohol use (Carey et al., 2011), insomnia (de Barros et al., 2012, Hom et al., 2016c), PTSS/PTSD (Heinrichs et al., 2005), and suicidality (Henderson et al., 2016; Kimbrel et al., 2016; Stanley et al., 2016, Stanley et al., 2015). Stigma-specific and structural barriers to mental health care were additionally assessed.
Section snippets
Participants and procedures
This study is a sub-investigation of a larger study examining suicidality among U.S. firefighters (Stanley et al., 2015). Firefighters were invited to participate through listserv and web-based announcements posted by firefighter organizations (February 2015). Respondents were presented with a web-based informed consent form and completed self-report measures through Qualtrics, a secure web-based platform. Total study participation time averaged 30 min. Participants were given the option of
Results
Bivariate correlations between study measures can be found in Table 3. Group differences between volunteer and career firefighters in psychiatric symptom levels and mental health treatment stigma can be found in Table 4. The following variables were included as controls in subsequent regression analyses, since statistically significant differences were observed between volunteer and career firefighters: age, sex, race, marital status, military status (Table 1); rank, years of service, emergency
Discussion
Volunteer firefighters in this sample reported markedly elevated levels of depression, posttraumatic stress, and suicidal symptoms (namely, suicide plans and attempts) as well as greater structural barriers to mental health treatment (e.g., cost, availability of resources) compared to career firefighters. In contrast, career firefighters in this sample reported relatively elevated levels of problematic alcohol use, which is in accord with past research (Haddock et al., 2012). There were no
Conclusions
Volunteer firefighters generally reported elevated psychiatric symptoms, including depression, posttraumatic stress, and suicide plans and attempts, whereas career firefighters reported elevated levels of problematic alcohol use. Greater structural barriers to mental health care (e.g., cost, availability of resources) may explain the increased psychiatric symptom levels observed among volunteer firefighters. Increased efforts are needed to prevent and treat psychiatric symptoms among
Conflicts of Interest
All authors report no conflicts of interest.
Financial disclosures
All authors report no financial disclosures.
Acknowledgements
This research was supported in part by a grant from the National Fallen Firefighters Foundation, and by a grant from the Military Suicide Research Consortium, an effort supported by the Office of the Assistant Secretary of Defense for Health Affairs under Award No. (W81XWH-10-2-0181). Dr. Kimbrel was supported by a Career Development Award (#IK2CX000525) from the Clinical Science Research and Development Service of the Department of Veterans Affairs’ Office of Research and Development.
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