Serving as a firefighter involves chronic stress and trauma exposures incurred during occupational events such as structure fires, wildfires, traffic accidents, suicides, drug overdoses, Sudden Infant Death Syndrome, domestic violence scenes, and disasters. Firefighters work long hours under shift work schedule demands and mandatory staffing, prompting deterioration of natural coping resources [e.g., social supports, restorative sleep; (1–4)]. Chronic physical and psychological stress exposures, paired with degradation of natural coping processes, leaves firefighters at risk for physical and mental health problems [e.g., (5–14)]. A recent study showed that more than 50% of firefighters may be at risk for PTSD, depression, anxiety, and/or alcohol use disorder (15). This is a population in need of culturally tailored, preventative, accessible treatment resources to facilitate mental health and wellbeing.

Evidence-based treatments are available for the common types of mental health problems that first responders are at risk for, including treatments for PTSD (Prolonged Exposure, Cognitive Processing, Eye Movement Desensitization and Reprocessing) and depression (Cognitive Behavioral Therapy Treatment approaches) (16–21). Notwithstanding the efficacy of evidence-based mental health treatments [e.g., see (22)], fewer than half of first responders in need of mental health care seek treatment (23). A recent survey of nearly 40,000 firefighters revealed that among firefighters with a probable PTSD diagnosis, fewer than 10% had sought treatment in the past month (24).

Reasons for not seeking mental health treatments are undoubtedly complex. For example, emergency responder cultures value archetypes of self-reliance, self-sufficiency, playing heroic roles, and saving other people at risk to the self (25). Firefighters are often unaware of the potential mental health risks for long-term effects of persistent stress (26), and/or lack the knowledge for where and how to access mental health providers trained in evidence-based approaches (27). Among firefighters who are identified as needing mental health services, seeking such services can be blocked by stigma and fear of negative professional consequences, losses of standing, promotion potential, and/or pay (10, 26, 28). Additionally, practical barriers exist for being able to attend health appointments consistently due to shift work, mandatory staffing practices, and associated time constraints (24, 27).

A recent community-based study identified four critical facilitators for improving mental health service use among first responders: increasing knowledge, reducing stigma, increasing positive experience with mental health providers, and removing time-based burdens (27). This study by Jones et al. (27) addressed initial steps in a Planned-Action based framework for translating research into mental health care practice for first responders having (step 1) identified the problem (i.e., first responders underutilizing mental health care), (steps 2 and 3) reviewed the evidence and adaptee toward innovation, and (step 4) assessed barriers to uptake [see (29, 30)]. The first responder community would benefit from interventions that translate this knowledge into practice.

In the current study, we sought to extend the next three steps in a Planned-Action framework by (a) developing an intervention that applies/translates known barriers and facilitators (27), (b) implementing the intervention, and (c) evaluating uptake and utilization (29, 30). Within the Planned-Action framework, we incorporated a rational stepped care design feature to optimize for cost-effectiveness, future scalability, and increased access in a scarce resource context (31–38). The overarching goal of the current manuscript is to describe the intervention development, implementation, and utilization process as a means to improve first responder mental health.

Ample evidence suggests that first responders are difficult to engage in mental health resources. Despite longstanding knowledge of mental health risks are incurred among firefighters as an occupational hazard, there is limited applied research and behavior service delivery that focuses on improving access and utilizization (27, 51). The goal of the present study was to describe an applied intervention aimed at decreasing barriers to access and promoting the utilization of services among firefighters.

In summary, we utilized a combined approach, applying barriers and facilitators identified by Jones et al. (27) into an intervention, thereby extending a Planned-Action framework. Specifically, Jones and colleagues identified these prime facilitators of mental health service utilization among first responders: increasing knowledge, reducing stigma, increasing positive experience with mental health providers, and removing time-based burdens. We intentionally targeted each of these factors (e.g., flexible scheduling using a telehealth platform; stigma reduction using an “opt-out” strategy and a normalizing “performance enhancement” focus [rather than a pathology orientation]; increase positive experience by providing cultural training for providers). Additionally, we implemented the intervention using a cost-conscious and utilization-boosting stepped care implementation design [see (52)].

Our findings show that the current intervention was engaged by ~56% of “at-risk firefighters.” More than half of those who screened positive and engaged in a telehealth visit were provided with recommendations for further mental health service follow-up (n = 38), among whom 76% (n = 29) followed through with these referrals. This is comparable to 62% recommendation adherence in other samples [e.g., (52)]. Our high level of adherence to follow-up recommendations suggests that low-intensity intervention such as the one presented is useful in promoting needed, preventative mental health service use among firefighters.

First responders are often thought of as individuals who move toward crises to come to the aid of others. This intervention mirrored that sentiment by “moving toward” first responders and meeting them where they are. The clinical scheduling assistant reached out to participants within 48–72 h after screening positive for risk. Prioritizing individualized communication likely increased participation with the stepped care intervention. Step 2 appointments were provided virtually, making it more feasible for participants to attend. It has been well-noted that aside from stigma-related barriers, structural barriers (53) often hinder first responders from engaging with mental health professionals. It is possible that follow through with the Step 2 session was boosted by the easily accessible format in this stepped care intervention.

It is also important to note that the number of firefighters who were referred for more than one clinical session was only ~17% of the total number who participated in this intervention (denominator = 229). This finding indicates the preliminary value in an approach such as ours for “right sizing” resource appropriations needed to provide substantive mental health services, although much work is yet to be done to further elucidate that cost/funding need across time (and to generalize beyond one fire department).

This study was limited by several factors. First, this intervention was implemented in a single fire department thus limiting the generalizability of findings to other departments. Further research needs to take this intervention system to multiple fire departments to increase power as well as account for potential differences in various stations. Second, this project addressed firefighters but no other first responder populations such as police officers, emergency medical technicians (EMTs), and emergency dispatch. To evaluate its effectiveness in other first responder fields this system needs to be tested in a variety of emergency service stations as well as among adequate numbers of first responders. Third, insufficient sleep was not measured in this sample in the Step 1 screening tool. It has been widely established that sleep problems are common among emergency personnel (54) due to several factors such as disruptions of circadian rhythm and exposure to occupational trauma (55). Examination of insufficient sleep should perhaps be included in any initiation of stepped care services, thus increasing opportunities to provide psychoeducation as well as individualized referrals to improve sleep. Fourth, funding constraints limited our ability to engage participants in qualitative interviews about their experience with the intervention. This is a critically missing component for future research to endeavor to maximally shape interventions to be effective across cultures. Fifth, some individuals who screened as “at-risk” chose not to participate in Step 2, and data on discontinuation was not gathered, such as reasons for discontinuing despite being identified with a mental health service need is an important next step. Future studies should aim to examine the reasons for declining participation to better serve this population. Sixth, we do not have comprehensive follow-up data on either the efficacy of the brief problem-focused interventions administered or the longer-term efficacy of engaging in this intervention. It is important for future studies with sufficient funding to pursue the value of such brief intervention approaches. Established dissemination and implementation frameworks [e.g., the Planned-Action framework; (29); see (30)] are built to provide a rigorous and larger-scale study of interventions such as this. Such work would help to improve and expand these promising preliminary findings, to promote high quality and best practices to help draw in the largest proportion of “in need” first responders.

While the research on mental health outcomes for first responders is limited, what does exist indicates that this group is at significant risk for psychiatric conditions and that they are hesitant to seek help. However, such hesitancy to seek help, whether it be due to stigma or barriers to access, should not be equated with disinterest in receiving help when needed or offered. The results of this project are encouraging as it shows that by providing appropriate and tailored levels of care, firefighters can be open to receiving mental health referrals and will engage with said referrals. The work of a first responder has always presented numerous challenges that increase the risk of psychopathology. But with the ever-increasing number of natural disasters, social unrest, and the ongoing COVID 19 pandemic, finding ways to increase access to mental health resources and decrease the stigma among those services is more important than ever. Much work remains to be done to evaluate the effectiveness of mental health treatment in this population.

The data presented in this article is not readily available given the nature of this research, participants of this study did not agree for their data to be shared publicly. Requests to access the data should be directed to aj.smith-2@dartmouth.edu.

The studies involving human participants were reviewed and approved by University of Utah IRB. The patients/participants provided their written informed consent to participate in this study.

HW and DFH wrote the manuscript. All authors contributed to the article and approved the submitted version.

Program Description Issued By US Department of Homeland Security (DHS), Federal Emergency Management Agency (FEMA)/Grant Programs Directorate (GPD), Catalog of Federal Domestic Assistance (CFDA) Number 97.044, CFDA Title Assistance to Firefighters Grants (AFG), Notice of Funding Opportunity Title FY 2018, Assistance to Firefighters Grants, Notice of Funding Opportunity Number DHS-18-GPD-044-00-99, Authorizing Authority for Program Section 33 of the Federal Fire Prevention and Control Act of 1974, Pub. L. No. 93-498, as amended (15 U.S.C § 2229), Appropriation Authority for Program Department of Homeland Security Appropriations Act, 2018 (Pub. L. No. 115-141), and Program Type New Grant ID: EMW-2018-FO-05385.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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