Mental health stigma and barriers to mental health care for first responders: A systematic review and meta-analysis
Introduction
Working as a first responder is one of a few occupations where individuals repeatedly put themselves in harm's way. First responder groups have historically included police officers (Cardozo et al., 2005, McCaslin et al., 2006), firefighters (Bryant and Harvey, 1995, Tak et al., 2007), search and rescue personnel (Brandt et al., 1995), and ambulance personnel (e.g., emergency medical technicians and paramedics) (Weiss et al., 1995). These professionals often experience taxing work demands (Peñalba et al., 2008) and routine exposure to physical and psychological stressors (Galloucis et al., 1999, McCaslin et al., 2006). Research has shown that these stressful work conditions are associated with the development of new mental health conditions and/or exacerbation of pre-existing mental health conditions (Marmar et al., 2006, Stellman et al., 2008, Wang et al., 2010) with some variation by country (e.g., posttraumatic stress disorder; see (Benedek et al., 2007)). These conditions are not only associated with distress and impairment in responders, but also at-work productivity loss, early retirement, alcohol abuse, divorce, and increased rates of suicide (Dowling et al., 2006, Miller, 1996, O'Hara et al., 2012). Although, to our knowledge, international estimates of the mental health burden experienced by first responders are not readily available, Kleim and Westphal (Kleim and Westphal, 2011) conducted a non-systematic review of primarily US-based samples and found prevalence rates of between 8% and 32% for PTSD and somewhat lower rates for depression. Within the United States, one of the authors (P.T.H.) has estimated that there are likely at least one-quarter million first responders suffering from full- or partial-PTSD (Haugen et al., 2012), making the provision of effective interventions for this population both necessary and justified.
Research across a wide variety of populations and settings demonstrates that as a result of barriers to care, many individuals with mental health difficulties never pursue treatment (Jayasinghe et al., 2005), delay treatment, fail to fully adhere to treatment regimens (P. Corrigan, 2004), or receive inadequate care (Griffiths et al., 2014). These barriers can include lack of perceived need for treatment, pessimism regarding the effectiveness of treatments, and/or not understanding the procedures and options for getting treatment (Andrade et al., 2014). However, the extent to which barriers identified in civilian or military samples generalize to first responders is unclear. Areas of particular concern for this population include negative evaluations by peers and supervisors, negative changes in job duties, and shift work that interferes with access to provided services.
Stigma is one of the most frequently identified barriers to mental health care. Mental health stigma has been conceptualized as a negative and erroneous attitude about a person, similar to a prejudice or negative stereotype, which leads to negative action or discrimination (P. W. Corrigan and Penn, 1999). High levels of mental health stigma have been associated with negative experiences and outcomes and may impact behavior, leading sufferers to avoid seeking help or not fully adhering to treatment recommendations (P. Corrigan, 2004). Rates of help-seeking behavior in first responders require further study, but in one US-based sample, slightly less than half of symptomatic World Trade Center (WTC) utility workers accepted referrals for mental health treatment (Jayasinghe et al., 2005).
Although a number of conceptual frameworks have been proposed describing the stigma of mental illness and its impact on health-seeking in civilian populations (Corrigan, 2004), and to a lesser extent, military populations (Ben-Zeev et al., 2012), to our knowledge, none have been developed specifically for first responders. However, responder culture shares several unique aspects of military culture which distinguish it from civilian populations and other non-responder occupations, and which may make military frameworks an appropriate basis for comparison. Such shared factors include: pre-employment screening for mental health disorders; access to employer-based health care; a demographic profile with significantly more men than women; and norms and values that place a premium on self-reliance in the face of obstacles (See Acosta et al., 2014). It remains to be seen whether and to what extent cultural differences between responders and military personnel are associated with different prevalences of mental health stigma and treatment seeking.
Ben-Zeev et al. (2012) have developed a military-specific conceptual model in which stigma can take three forms: (1) public stigma - the extent to which an individual is aware of stereotypes held by the public about individuals who utilize mental health services (Link, 1987, Skinner et al., 1995); (2) self stigma - the application of these stereotypes to oneself, leading to internalized devaluation and disempowerment (P. W. Corrigan, 2002); and (3) label avoidance – the extent to which individuals purposefully do not acknowledge symptoms or participate in mental health services in order to avoid the stigma and negative consequences a formal diagnostic label might entail (Ben-Zeev et al., 2012). Stigma is conceptualized as a staged process in which: first, mental illness is inferred from explicit cues (e.g., PTSD symptoms); second, these stigmatized cues elicit negative beliefs or stereotypes (e.g., a responder is “weak”); and third, the stigmatized individual agrees with these stereotypes and experiences resulting negative emotions (e.g., shame at being “weak”). Clement et al. conducted a review on the extent to which stigma is present in first responders and found higher levels of mental health stigma among military personnel (a group theoretically similar to first responders) versus other populations (Clement et al., 2015).
Our objectives were to (a) conduct a systematic review of the literature regarding specific barriers to mental health care and stigma concerning help-seeking for mental health conditions identified in first responders and, (b) where possible, perform a meta-analysis to gain more robust estimates of the prevalence of barriers to care and stigma in first responders and, (c) identify the degree to which the findings are associated with mental health conditions and engagement in mental health treatment.
Section snippets
Method
This meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and was registered at the PROSPERO International Prospective Register of Systematic Reviews (CRD42015017532). Two study investigators (P.T.H. and M.J.N.) independently screened the results of the literature searches and included or excluded studies based on pre-defined eligibility criteria.
Results
Fig. 1 shows the process of study selection. The original searches yielded 2868 records. After duplicates were removed and titles and abstracts were screened, 196 articles were considered for inclusion. One hundred and eighty-two records were excluded: 156 did not include a variable representing a barrier to care or stigma in the study or the barrier variable was not included in the analysis, 22 records were reports of interventional studies or were review articles, and four studies did not
Main findings from the systematic review
All 14 studies measured stigma. Approximately a third of participants endorsed stigma items. Five of the 14 studies measured barriers to care. Of those studies less than a quarter of those surveyed endorsed a barrier to care. Inspection of the studies by type of first responder group did not reveal considerable differences on stigma or barriers to care between police officers and other first responder groups (rescue workers, paramedic trainees, and combat medics).
The most commonly endorsed
Discussion
The goal of the present study was to summarize the evidence base regarding the nature and impact of barriers to care and mental health stigma in first responders. The results from the meta-analysis indicate that on average, about one in three first responders (33.1%) experiences stigma regarding mental health and that about one in eleven first responders (9.3%) experience barriers to care. The most frequently endorsed stigma-related concerns were fears regarding the confidentiality of services
Conflict of interest
All authors declare that they have no conflicts of interest.
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