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First Responder Mental Health

Written by Dr. Rieka Yu
Published on June 13, 2024
Research Highlights

First responders are susceptible to posttraumatic stress disorder after witnessing traumatic events while on duty.

Stress from traumatic events as well as occupational stress affects workforce stability.

Organizational changes in the workplace can mitigate the effects of traumatic events for first responders.

First responders have work-related mental health struggles.

First responders include but are not limited to paramedics, hospital emergency staff, firefighters, and police officers. Due to the nature of their work, first responders witness traumatic events that involve the injury or death of patients or civilians and/or experience direct threats (Alden et al. 2008).

  • In Belgian hospitals, 87% of emergency nurses witnessed or experienced at least one traumatic event in the last six months (Adriaenssens et al. 2012).
  • One U.S. survey found 67% of Emergency medical Technicians (EMTs) had been physically assaulted while providing services (National Association of EMTs 2019).


Between 7-37% of first responders have posttraumatic stress disorder (PTSD) symptoms (Table 1). First responders also suffer from other mental disorders related to depression and anxiety (Regehr et al. 2010, Carleton et al. 2018).


PTSD in first responders has been associated with health-related problems such as high cortisol levels, high resting heart rates, and poor sleep quality (Bergen-Cico et al. 2015). In a Canadian survey, paramedics indicated they had struggled with alcohol abuse after exposure to a traumatic event (Regehr et al. 2010).


Barriers and stigma prevent first responders from seeking mental healthcare. First responders fear judgement and negative impacts on their careers, and experience shame for feeling trauma symptoms (Royle et al. 2009, Haugen et al. 2017). Barriers for first responders accessing mental healthcare include difficulty (Haugen et al. 2017):

  • scheduling appointments
  • getting time off
  • knowing where to get help


Pay and health concerns drive turnover in the first responder workforce.

In the U.S., a survey of hospitals found 23% and 15% of emergency nurses left their positions in 2017 and 2018, respectively (Castner et al. 2021). Compared to all registered nurses, a higher percentage of emergency nurses left their job in 2017.


Another survey of EMS agencies found that about 63% of agencies had turnover in the past six months, with an overall average annual turnover rate of 11% (Patterson et al. 2010).

  • Turnover was highest among volunteer-only staff and mixed paid/volunteer staff.
  • Across all agencies, the median cost of turnover was $71,614 (based on costs to advertise, recruit, train, and costs associated with vacancies and hiring).


In a study of nine states, 80% of EMTs stayed in the workforce from 2017 to 2019 and 82% stayed from 2018 to 2020 (Kurth et al. 2023). The per-state rate of EMTs leaving the workforce ranged from 16-26%.

  • The National Association of EMTs found that 44% of EMTs leaving the job planned to do so due to concern for their physical and mental health (National Association of EMTs 2022).


Social and organizational support can help first responders with mental health struggles.

Having positive working relationships, social support from the community, and acknowledgment of a first responder’s role can mitigate psychological stress (Vaughan et al. 2016, Lawn et al. 2020, Bevan et al. 2022). Some Canadian emergency rooms identified lack of staff as leading to greater exposure to trauma due to people handling more patients at once or working double shifts (Vaughan et al. 2016). Additionally, self-compassion is correlated with resilience against stressors (Lanza et al. 2018).


One study suggests organizations should provide designated time for workers to find closure after a traumatic event (Vaughan et al. 2016). It also found that supervisors need to be able to identify posttraumatic stress symptoms in workers and push them to find care. In a study of fire and police personnel, adding a standardized PTSD screening protocol increased the rate of positive PTSD diagnoses from 1% to 5% (Robertson 2019). In addition, civilian responders particularly struggle with trauma because they lack access to occupational resources.


Evidence suggests trauma-focused psychotherapies can also reduce posttraumatic stress symptoms in first responders (Alden et al. 2021). See our Science Notes Posttraumatic Stress Disorder and Medical Psilocybin Use for an overview on PTSD treatments and the potential role psilocybin has in treating certain disorders.


Table 1. PTSD prevalence in different first responders. Data shows the range of PTSD prevalence (%) found in different studies and the country in which the study took place. Table adapted from Kleim & Westphal (2011). See PDF for clickable links.



Adriaenssens J, de Gucht V, & Maes S. (2012). The impact of traumatic events on emergency room nurses: Findings from a questionnaire survey. International Journal of Nursing Studies. 49(11), 1411-1422. https://www.sciencedirect.com/science/article/abs/pii/S0020748912002258.

Alden LE, Regambal MJ, & Laposa JM. (2008). The effects of direct versus witnessed threat on emergency department healthcare workers: Implications for PTSD Criterion A. Journal of Anxiety Disorders. 22(8), 1337-1346. https://www.sciencedirect.com/science/article/abs/pii/S0887618508000479.

Alden LE, Matthews LR, Wagner S, Fyfe T, et al. (2021). Systematic literature review of psychological interventions for first responders. Work & Stress. 35(2), 193-215. https://www.tandfonline.com/doi/abs/10.1080/02678373.2020.1758833.

Andrews L, Joseph S, Shevlin M, & Troop N. (2006). Confirmatory factor analysis of posttraumatic stress symptoms in emergency personnel: An examination of seven alternative models. Personality and Individual Differences. 41(2), 213-224. https://www.sciencedirect.com/science/article/abs/pii/S0191886906000584?via%3Dihub.

Bennett P, Williams Y, Page N, Hood K, & Woollard M. (2004). Levels of mental health problems among UK emergency ambulance workers. Emergency Medicine Journal. 21, 235-236. https://emj.bmj.com/content/21/2/235.

Bergen-Cico D, Lane S, Thompson M, Wozny S, et al. (2015). The impact of post-traumatic stress on first responders: analysis of cortisol, anxiety, depression, sleep impairment and pain. International Paramedic Practice. 5(3), 78-87. https://www.magonlinelibrary.com/doi/abs/10.12968/ippr.2015.5.3.78.

Bevan MP, Priest SJ, Plume RC, & Wilson EE. (2022). Emergency First Responders and Professional Wellbeing: A Qualitative Systematic Review. International Journal of Environment Research and Public Health. 19(22), 14649. https://www.mdpi.com/1660-4601/19/22/14649.

Carleton RN, Afifi TO, Turner S, Taillieu T, et al. (2018). Mental Disorder Symptoms among Public Safety Personnel in Canada. The Canadian Journal of Psychiatry. 63(1), 54-64. https://journals.sagepub.com/doi/pdf/10.1177/0706743717723825.

Castner J, Bell SA, Castner M, & Couig MP. (2021). National estimates of the reserve capacity of registered nurses not currently employed in nursing and emergency nursing job mobility in the United States. Annals of Emergency Medicine. 78(2), 201-211. https://www.ncbi.nlm.nih.gov/pmc/articles/.

Clohessy S, & Ehlers A. (1999). PTSD symptoms, response to intrusive memories and coping in ambulance service workers. Clinical Psychology. 38(3), 251-265. https://bpspsychub.onlinelibrary.wiley.com/doi/abs/10.1348/014466599162836?sid=nlm%3Apubmed.

Haugen PT, McCrillis AM, Smid GE, & Nijdam MJ. (2017). Mental health stigma and barriers to mental health care for first responders: A systematic review and meta-analysis. Journal of Psychiatric Research. 94, 218-229. https://www.sciencedirect.com/science/article/abs/pii/S0022395617305101.

Jonsson A, Segesten K, & Mattsson B. (2003). Post-traumatic stress among Swedish ambulance personnel. Emergency Medicine Journal. 20, 79-84. https://emj.bmj.com/content/20/1/79.

Kleim B, & Westphal M. (2011). Mental health in first responders: A review and recommendation for prevention and intervention strategies. Traumatology, 17(4), 17-24. https://psycnet.apa.org/doiLanding?doi=10.1177%2F1534765611429079.

Kurth JD, Powell JR, Gage CB, Fauvel AD, et al. (2023). Evaluating changes in the emergency medical services workforce: A preliminary multistate study. Journal of the American College of Emergency Physicians Open. 4(3), e12975. https://onlinelibrary.wiley.com/doi/full/10.1002/emp2.12975.

Lanza A, Roysircar G, & Rodgers S. (2018). First responder mental healthcare: Evidence-based prevention, postvention, and treatment. Professional Psychology: Research and Practice. 49(3), 193-204. https://psycnet.apa.org/record/2018-28691-003.

Laposa JM, Alden LE, Fullerton LM. (2003). Work stress and posttraumatic stress disorder in ED nurses/personnel (CE). Journal of Emergency Nursing. 29(1), 23-38. https://www.sciencedirect.com/science/article/abs/pii/S0099176702699106

Lawn S, Roberts L, Willis E, Couzner L, et al. (2020). The effects of emergency medical service work on the psychological, physical, and social well-being of ambulance personnel: a systematic review of qualitative research. BMC Psychiatry. 20(348). https://link.springer.com/content/pdf/10.1186/s12888-020-02752-4.pdf.

National Association of Emergency Medical Technicians. (2019). Violence Against EMS Practitioners. https://www.naemt.org/docs/default-source/2017-publication-docs/naemt-violence-report-web-10-02-2019.pdf?Status=Temp&sfvrsn=b700d792_2.

National Association of Emergency Medical Technicians. (2022). EMS Workforce Satisfaction and Engagement. https://naemt.org/docs/default-source/2017-publication-docs/national-report-on-engagement-and-satisfaction-survey-12-03-2022.pdf?sfvrsn=fbf7f793_2.

Patterson PD, Jones CB, Hubble MW, Carr M, et al. (2010). The longitudinal study of turnover and the cost of turnover in EMS. Prehospital Emergency Care. 14(2), 209-221. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2883888/.

Regehr C, Hill J, & Glancy G. (2000). Individual predictors of traumatic reactions in firefighters. The Journal of Nervous and Mental Disease. 188(6), 333-339. https://journals.lww.com/jonmd/abstract/2000/.

Regehr C, Goldberg G, & Hughes J. (2010). Exposure to human tragedy, empathy, and trauma in ambulance paramedics. American Journal of Orthopsychiatry. 72(4), 505-513. https://onlinelibrary.wiley.com/doi/abs/10.1037/0002-9432.72.4.505.

Robertson, EW. (2019). Implementation of a standardized screening protocol to improve post-traumatic stress disorder surveillance in first responders. Journal of Occupational and Environmental Medicine. 61(12), 1041-1044. https://journals.lww.com/joem/abstract/2019/.

Royle L, Keenan P, & Farrell D. (2009). Issues of stigma for first responders accessing support for post traumatic stress. International Journal of Emergency Mental Health. 11(2), 79-85. https://pubmed.ncbi.nlm.nih.gov/19927494/.

Vaughan AD, Moran CB, Pearce LDR, & Hearty L. (2016). The influence of organizational support on the life course of trauma in emergency responders from British Columbia. Journal of Workplace Behavioral Health. 31(3), 125-143. https://www.tandfonline.com/doi/abs/10.1080/15555240.2016.1195693.

Wagner D, Heinrichs M, & Ehlert U. (1998). Prevalence of symptoms of posttraumatic stress disorder in German professional firefighters. The American Journal of Psychiatry. 155(12), 1727-1732. https://ajp.psychiatryonline.org/doi/full/10.1176/ajp.155.12.1727.

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