Review of Mental Health in First Responders and Military Personnel Ibolja Cernak, M.D., Ph.D., M.E., MHS E-mail:
[email protected] Professor & Chair Chair in Military and Veterans Rehabilita6on Medicine University of Alberta Faculty of Rehabilita6on
MENTAL HEALTH IMPAIRMENTS IN GENERAL POPULATION • Mental health problems are prevalent in all countries; thus, they represent a major public health issue even before any disaster arises. • On average, in the absence of any major disasters, adult popula6ons have: – around 10-‐15% with common mental disorders (largely depression and anxiety), – 0.5-‐1% psychosis; and – a variable prevalence of alcohol and substance abuse depending on local availability and culture;
• Child and adolescent popula6ons have around 10% of mental disorders at any one 6me. (Jenkins et al 2009; Social Psychiatry and Psychiatric Epidemiology 44, 899-‐904.).
GENERAL POPULATION UNDER MAJOR STRESS • The most common mental health consequences of disasters are increased rates of: – – – –
depression, anxiety, post-‐traumaQc stress disorder, and medically unexplained somaQc symptoms.
• OUen aUer disaster, there is an increase in: – suicidal behaviour, – domesQc violence, and – substance abuse
(Goldstein, Osofsky & Lichtveld, N Engl J Med 2011; 364:1334-‐1348)
• The excess morbidity rate of psychiatric disorders in the first year aUer a disaster is in the order of 20%-‐37% (Bromet et al., Clin Oncol (R Coll Radiol). 2011 May;23(4): 297-‐305).
WORK-‐RELATED STRESS & ITS EFFECTS in EMERGENCY MEDICAL SERVICES PERSONNEL CHRONIC STRESS: “Rela6vely enduring problems, conflicts and threats that many people face in their daily lives”.
(Pearlin LI. The sociological study of stress. J Health Soc Behav. 1989;30:241–56.)
CRITICAL INCIDENT STRESS: Typically associated with the provision of pa6ent care and is defined as “any situa6on faced by emergency services personnel that causes them to experience unusually strong emo6onal reac6ons which have the poten6al to interfere with their ability to func6on either at the scene or later.” (Boudreaux E, Mandry C. The effects of stressors on emergency medical technicians (part II): a cri6cal review of the literature, and a call for further research. Prehosp. Disaster Med. 1996;11:302–7.)
• “Exposure to both chronic and criQcal incident stressors increases the risk of EMS providers’ developing a posjrauma6c stress reac6on (PTSS). • Higher levels of chronic stress, criQcal incident stress, and alcohol use significantly related to an increased level of PTSS. • Further, for those repor6ng high levels of alcohol use or cri6cal incident stress, interac6ons with high levels of chronic opera6onal stress were associated with higher rates of PTSS. • These findings indicate that ajen6on must be paid to levels of stress associated with both cri6cal incident exposure as well as the chronic stress providers experience on a day-‐ to-‐day basis”(Donnelly E. Work-‐related Stress and Posjrauma6c Stress in Emergency Medical Services. Prehospital Emergency Care. 2012;16:76–85.)
POSTTRAUMATIC STRESS
InteracQons of CriQcal Incident Stress and Alcohol Use with Chronic OperaQonal Stress & Simultaneous Entry in Regression of Pos\raumaQc Stress Symptomatology
LOW CHRONIC STRESS MODERATE CHRONIC STRESS HIGH CHRONIC STRESS Lowest ter6le
Middle ter6le
Highest ter6le
CRITICAL INCIDENT STRESS
Lowest ter6le
Middle ter6le
Highest ter6le
ALCOHOL USE
(Donnelly E. Work-‐related Stress and Posjrauma6c Stress in Emergency Medical Services. Prehospital Emergency Care. 2012;16:76–85.)
Lima Ede P, Assunção AÁ. Rev Bras Epidemiol. 2011 Jun;14(2):217-‐30.
[Prevalence and Factors Associated with Pos\raumaQc Stress Disorder (PTSD) in Emergency Workers: A SystemaQc Literature Review]. • Seven databases were consulted: Medline via Pubmed, PsycINFO, LILACS, SciELO, BDENF, DISASTERS, and MEDCARIB, between September 10 and 25, 2009. • The key-‐words included: terms related to emergency services/workers, Posjrauma6c stress disorder, working condi6ons, and occupa6onal health. • QuanQtaQve observaQonal studies on PTSD prevalence and determinant or associated factors regarding the health of firefighters, emergency ambulance personnel, Red Cross workers, and medical emergency workers were included. • The prevalence of the disease ranged: from absence of reported cases to a rate of 38.5%. • The prevalence of PTSD in emergency workers were associated with: o Socio-‐demographic characteris6cs, o Biological and psychological features & morbidity, o Exposure to occupa6onal and non-‐occupa6onal trauma6c events, and o Work and job features
NEGATIVE WORK-‐RELATED EFFECTS IN EMERGENCY MEDICAL SERVICES • • • • •
Increased work absences, Burnout, Illness, High turnover rates, and With up to 20% of paramedics leaving their workplaces each year.
(Alexander, Weiss, Braude, Ernst, & Fullerton-‐Gleason. American Journal of Emergency Medicine, 27(7), 830-‐837, 2009).
• Work stress and organizaQonal problems are some of the reasons paramedics report for leaving their workplaces (Perkins, DeTienne, Fitzgerald, Hill, & Harwell. Prehospital Emergency Care, 13, 456-‐461, 2009).
• Of the paramedics who con6nue to work, almost 30% take mental health leave at least once during their careers (Regehr & Millar. Traumatology, 13(1), 49-‐58.2007).
Drewitz-‐Chesney C. Workplace Health Saf. 2012 Jun;60(6):257-‐63.
Pos\raumaQc stress disorder among paramedics: exploring a new soluQon with occupaQonal health nurses using the O\awa Charter as a framework.
PTSD in POLICE • The incidence of current duty-‐related PTSD in police officers has been found to vary between 7% and 19% (Carlier et al., 1997; Gersons, 1989; Robinson et al., 1997; Maia et al., 2007), with greater rates for those with sub-‐syndromal PTSD. • Among 262 Dutch police officers interviewed at 2 weeks, 3 months, and 12 months aUer experiencing a cri6cal incident, 7% met full diagnos6c criteria for current PTSD on at least one of the 6me points. • Moreover, 34% suffered from pos\raumaQc stress symptoms or sub-‐syndromal PTSD at some point during the study (Carlier et al., 1997). • Among 157 Brazilian police officers, 9% met full criteria for PTSD and an addi6onal 16% met criteria for sub-‐syndromal PTSD (Maia et al., 2007). (NIMH,'2009)'
Conn Med. 2012 Oct;76(9):525-‐31.
Mental-‐health CondiQons, Barriers to Care, and ProducQvity Loss among Officers in an Urban Police Department. Fox J, Desai MM, Bri\en K, Lucas G, Luneau R, Rosenthal MS.
• Police officers are frequently exposed to situa6ons that can nega6vely impact their mental health. • In the popula6on of urban police department personnel, the study focused on; 1) The prevalence of post-‐trauma6c stress disorder (PTSD), depression, and alcohol abuse 2) Pajerns of and barriers to mental-‐health services u6liza6on; and 3) The impact these condi6ons have on produc6vity loss. • Among 150 officers, PTSD (24%), depression (9%), and alcohol abuse (19%) were common. • Only 46.7% had ever sought mental-‐health services; • The most commonly cited barriers to accessing services were concerns regarding confiden6ality and the poten6al “negaQve career impact.” • Officers with mental-‐health condi6ons had higher producQvity loss (5.9% vs 3.4%, P33.3 pMol/mL; 10% HIGHER than 33.3 pMol/mL NORMAL: 0.05 -‐ 33.3 pMol/mL
CorQsol
(Since cor6sol helps one deal with stress, low cor6sol levels will affect one's ability to cope well in stressful situa6ons. Hypersensi6vity, irritability, headache, dizziness, unexplained anxiety, fear, fa6gue and loss of appe6te are some of the most common symptoms of low cor6sol. Chronic stress is the most common cause of low cor6sol levels).
0.216 ± 0.109 μg/dL; Range: 0.039 to 0.564 μg/dL; 18.33% lower than 0.122 μg/dL NORMAL AM range for 31-‐50 males: 0.122 – 1.551 μg/dL)
Testosterone
93.08 4 ± 39.24 pg/mL; Range: 22.67 to 215 pg/mL; in 17% males lower than 64.55 Normal range for 31-‐50 males: 64.55 – 248.83 pg/mL ; females 10.3 – 87.18
Dehydroepiandrosterone (DHEA)
129.86 ± 99.46 pg/mL; Range: 14.92 to 659 pg/mL; 5% higher than 291 pg/mL NORMAL: 15.9 – 291.1 pg/mL
BURNOUT SYNDROME IN APPROXIMATELY 30% PARTICIPANTS DURING THE PRE-‐DEPLOYMENT TRAINING * IMMUNE SYSTEM !" * SYSTEMIC ANS: # * ENDOCRINE SYSTEM (HEALING & REGENERATION): !
MULTIPLE HEALTH ASSESSMENTS IN PREEMPTING WORK STRESS-‐ RELATED HEALTH IMPAIRMENTS IN EMERGENCY MEDICAL SERVICES – LEVERAGING KNOWLEDGE FROM MILITARY RESEARCH Educating/Evaluating - Edu. Institutes - Intake Assess - Self Assess - Hiring tools
Building/Supporting - Wellness
Readiness/Response
- Peer Support - Resiliency Programs - EAP
- CISM
-Career Planning - Family Support
EVENT!!
(for!example,!INJURY!or!EXPOSURE!to! PATHOLOGICAL!FACTORS)!
- Trauma Counselling - EAP - WCB
EVENT!!
NORMAL/( HEALTHY(
Awareness
NORMAL/( HEALTHY( PATHOLOGICAL/( ILL(
MulCple!funcConal!baselines! Comparison!with!individual!norms! (physiological,!cogniCve,!emoConal)! to!predict!disease!development! !to!establish!individual!norms! and!progress.!
(for!example,!INJURY!or!EXPOSURE!to! PATHOLOGICAL!FACTORS)!
EVENT!!
(for!example,!INJURY!or!EXPOSURE!to! PATHOLOGICAL!FACTORS)!
PATHOLOGICAL/( ILL( MulCple!funcConal!baselines! Comparison!with!individual!norms! (physiological,!cogniCve,!emoConal)! to!predict!disease!development! !to!establish!individual!norms! and!progress.!
- Re-integration - RTW Plans - WCB
(for!example,!INJURY!or!EXPOSURE!to! PATHOLOGICAL!FACTORS)!
EVENT!!
NORMAL/( HEALTHY(
Rebuild/Restore
NORMAL/( HEALTHY(
PATHOLOGICAL/( ILL( MulCple!funcConal!baselines! Comparison!with!individual!norms! (physiological,!cogniCve,!emoConal)! to!predict!disease!development! !to!establish!individual!norms! and!progress.!
Culture
PATHOLOGICAL/( ILL( MulCple!funcConal!baselines! Comparison!with!individual!norms! (physiological,!cogniCve,!emoConal)! to!predict!disease!development! !to!establish!individual!norms! and!progress.!
Research
Courtesy of Darren Sandbeck M.A. EMT-‐P; Senior Provincial Director/Chief Paramedic Alberta Health Services Emergency Medical Services