Review of Mental Health in First Responders and Military Personnel

Review  of  Mental  Health  in  First  Responders  and   Military  Personnel   Ibolja Cernak, M.D., Ph.D., M.E., MHS E-mail: [email protected] Profes...
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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  

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