Mental Health and Occupational Stress in the Emergency Medical Services and 911 Workforces

OBJECTIVES: This Systematic Review addresses the mental health of the Emergency Medical Services (EMS) and 911 telecommunicator workforces. We addressed Key Questions (KQs) related to the: (1) incidence, prevalence, and severity of mental health and occupational stress issues; (2) benefits and harms of interventions to promote resistance and resilience regarding these issues; (3) contextual and implementation factors for practices to address these issues; and (4) future research needs. DATA SOURCES: We searched Medline®, Embase®, Cochrane CENTRAL, PsycINFO®, CINAHL®, journals not indexed in Medline®, ClinicalTrials.gov, and Websites from January 1, 2001, to June 11, 2024. To increase applicability to the U.S. decision-making context, we restricted to studies conducted in high-income countries. REVIEW METHODS: We used DistillerSR® for screening and the Systematic Review Data Repository Plus for data extraction. We assessed the risk of bias, conducted meta-analyses, and evaluated strength of evidence (SoE) using standard methods. We registered the protocol in PROSPERO (registration number CRD42023465325). RESULTS: We included 187 studies (2 randomized controlled trials, 1 nonrandomized trial, 5 pre-post studies, 6 cohort studies, and 173 cross-sectional studies). KQ1: We included 179 studies. No study reported on incidence of any outcome. Among telecommunicators during routine practice, prevalence estimates were: any depression, 15.5 percent; suicidal ideation, 12.4 percent; suicide plans, 5.7 percent; suicide attempts, 0.7 percent; alcohol abuse, 15.5 percent; high/extreme peritraumatic distress, 5 percent; high secondary traumatic stress, 16.3 percent; and acute stress disorder, 17 percent (low SoE for each). Among telecommunicators after critical incidents, the prevalence of high and medium general stress were 39.7 and 28.2 percent, respectively (low SoE). Among EMS clinicians during routine practice, prevalence estimates were: suicidal ideation, 33 percent; suicide plans, 8.7 to 10.9 percent; and suicide attempts, 2.8 to 5.6 percent (moderate SoE). Among EMS clinicians during routine practice or after critical incidents, the prevalence of depression, anxiety, posttraumatic stress disorder (PTSD), burnout, and stress varied considerably (low SoE for each). Regarding severity (based on mean levels), among telecommunicators during routine practice, depressive symptoms and stress were mild/low to moderate and burnout was mild to severe (moderate SoE). Peritraumatic distress was moderate and secondary traumatic stress was mild (low SoE). Among telecommunicators after critical incidents, mean levels of burnout and general stress were moderate (low SoE). Among EMS clinicians during routine practice, mean levels of depressive symptoms were minimal to mild, while mean levels of anxiety and operational and organizational job stress were mild to moderate, mean levels of general stress and burnout were mild to severe, mean levels of secondary traumatic stress were mild, and mean alcohol use was low risk (moderate SoE). The Suicide Behaviors Questionnaire-Revised (SBQ-R) mean score was 4.92 (95% confidence interval, 2.44 to 7.39; 4 studies; SBQ-R ≥ 7 implies at risk of suicide; moderate SoE). The mean level of moral injury was moderate (low SoE). Among EMS clinicians after critical incidents, mean levels of depressive symptoms were minimal to mild and for anxiety were mild to moderate (moderate SoE). Some modifying factors (e.g., more trauma exposure, more hours per week, more burnout, higher call volumes) were associated with poor outcomes. KQ2: We included nine studies. Mindfulness-building interventions targeting resistance and resilience among EMS clinicians were associated with reduced burnout at up to 6 months of follow-up (low SoE). KQ3: We included five studies. We found no evidence regarding effective telecommunicator workforce practices to improve mental health and occupational stress issues. KQ4: Future research should evaluate mindfulness-based interventions and prioritized outcomes, using randomized trials or non-randomized studies that account for important confounders. CONCLUSIONS: This Systematic Review documents the prevalence and severity of mental health and occupational stress issues in the EMS and telecommunicator workforces. To strengthen preventive and early supportive interventions, attention should be given to factors associated with poor outcomes.