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European Journal of Psychotraumatology logoLink to European Journal of Psychotraumatology
. 2025 Jun 30;16(1):2512680. doi: 10.1080/20008066.2025.2512680

Role of peer support in mitigating PTSD and suicide risk among firefighters experiencing colleagues’ death

Rol del apoyo entre pares en la mitigación del TEPT y del riesgo de suicidio entre bomberos que han presenciado la muerte de un compañero

Bora Kim a, Heyeon Park b, Johanna Inhyang Kim c, Sohee Oh d, Sun Young Moon e, Ji-Hye Lee e, Jeong Hyun Kim e,f,g,CONTACT
PMCID: PMC12210409  PMID: 40586346

ABSTRACT

Background: The impact of witnessing a colleague’s line-of-duty death or suicide on firefighters is profound, potentially elevating the risk of post-traumatic stress disorder (PTSD) and suicide risk. Although violent loss has been acknowledged as more traumatic than natural loss, research exploring the specific outcomes of experiencing a colleague’s death within these contexts are scarce.

Methods: Of 58,299 South Korean firefighters, 53,980 (92.6%) participated in the survey. Posttraumatic symptoms, suicide risk, alcohol-related problems, emotional damage due to emotional labour, and perceived support from colleagues were assessed. Moderated mediation effects were analyzed using SPSS PROCESS macro Model 88.

Results: The findings highlighted the significant mediating roles of emotional damage due to emotional labour and alcohol-related problems in the relationship between colleagues’ death experiences and PTSD or suicide risk. Additionally, peer support mitigated the impact of experiencing colleagues’ death on PTSD symptoms and suicide risk.

Conclusions: Our study sheds light on the complex interplay between grief, traumatic responses, and peer support in firefighters, suggesting enhancing peer support as an important intervention component to mitigate the psychological impact of witnessing a colleague’s death. This study not only broadens our understanding of firefighter bereavement and mental health challenges but also underscores the importance of targeted therapeutic strategies to prevent PTSD and suicidal behaviours in this high-risk population.

KEYWORDS: Firefighters, PTSD, suicide risk, emotional damage due to emotional labour, alcohol-related problems, peer support

HIGHLIGHTS

  • Witnessing a colleague's death increases firefighters’ risk of developing PTSD and suicide risk.

  • Peer support acts as a protective factor against these negative outcomes, mitigating the psychological impacts.

  • High levels of peer support significantly reduce the psychological impacts from witnessing a colleague's death, emphasising the importance of strong support systems within fire departments.

1. Introduction

Firefighters play a crucial role in disaster and emergency response by undertaking tasks such as fire suppression, medical assistance, and rescue operations to protect the lives and property of the public (Back et al., 2023). These duties expose firefighters to numerous hazards ranging from minor injuries to life-threatening incidents (Serrano-Ibáñez et al., 2023). Research has shown that firefighters are at higher risk of developing psychiatric disorders, including post-traumatic stress disorder (PTSD), depression, suicidal ideation, sleep disorders, and alcohol-related disorders (Wagner et al., 2021). The global prevalence of PTSD among firefighters varies from 6.4% to 57% compared to 6% in the general population (Salleh et al., 2020). Experiencing a colleague's line-of-duty death, or suicide is a traumatic event. According to the Korean National Fire Agency (2021), 49 firefighters have died in the line-of-duty in the last 10 years, and the number of suicides was 97. These incidents evoke profound sorrow and guilt, heightening firefighters’ awareness of their own mortality and inducing death-related anxiety (Kim, 2020). Firefighters often perform their duties under suppressed emotional conditions because of the immediate deployment requirements of their roles (Yoon, 2023).

Loss of a loved one causes deep psychological trauma and induces sorrow, anger, guilt, and anxiety (Shuchter & Zisook, 1993). These reactions typically diminish over time through the natural bereavement processes (Holland et al., 2009). However, an abrupt or violent death can severely disrupt this process, leading to traumatic grief, complicated grief, PTSD, and an increased risk of suicide (Prigerson et al., 1997). Individuals experiencing violent loss are approximately five times more likely to develop posttraumatic stress responses than those experiencing natural loss (Djelantik et al., 2017). In addition, 63% of patients who experience traumatic loss exhibit significant PTSD symptoms (Momartin et al., 2004). Losing a loved one to death by suicide, one of the most prevalent forms of traumatic loss, doubles or triples the risk of suicide for the bereaved (Cerel et al., 2016; Song et al., 2012). For firefighters, the line-of-duty death or suicide of colleague can be perceived as a sudden and traumatic loss. Despite these findings, few studies have examined how the death of fellow firefighters contributes to psychiatric disorders.

Firefighters frequently perform their duties while suppressing personal emotions, a phenomenon conceptualised as emotional labour-the regulation of emotional expression to meet organisational norms (Brotheridge & Grandey, 2002). During rescue efforts and crisis response, firefighters often conceal their own distress to provide reassurance to affected individuals (Cho et al., 2017; Goodwin et al., 2011; Oubari, 2007). While emotional regulation can facilitate professional performance in the short term (Adelmann & Zajonc, 1989; Ashforth & Humphrey, 1993), chronic emotional suppression may result in emotional exhaustion and hinder psychological adjustment, particularly when grieving a colleague’s death (Ashforth & Humphrey, 1993; Eisma & Stroebe, 2021; Gupta & Bonanno, 2011). Firefighters dealing with a colleague’s death may experience emotional damage due to emotional labour as they continue their duties amid personal grief without adequate mourning time.

Alcohol-related problems are another key mental health concern among firefighters and often arise from stress (Smith et al., 2019). Firefighters reported high rates of hazardous drinking, with over half consuming excessive amounts in the past month (Haddock et al., 2015, 2017). According to the self-medication hypothesis (Hawn et al., 2020), alcohol may be used to blunt psychological distress. This view is supported by prior studies that individuals frequently consume alcohol to regulate negative emotions, which can lead to alcohol-related problems and impaired functioning (Conger, 1956; Cooper et al., 1992; Khantzian, 1985; Seo & Yang, 2011; Turner et al., 2018). Alcohol problems are particularly prevalent among individuals with PTSD. Dell’Aquila and Berle (2023) found that repeated trauma exposure increases the likelihood of alcohol use disorder by 1.81 times. Individuals with PTSD are more prone to using alcohol in response to stress and less likely to engage in proactive coping (Luciano et al., 2022). Kim et al. (2011) further emphasised that poor emotional tolerance and reliance on alcohol to escape distress elevate the risk of problematic use. Firefighters might use alcohol to manage stress, with drinking to cope linked to higher consumption (Meyer et al., 2012; Tomaka et al., 2017). Such use is often triggered by psychological distress related to irregular work hours and repeated trauma exposure (Lebeaut et al., 2020).

Social support is widely recognised as a protective factor against the psychological impact of stress, including trauma-related and complicated grief reactions (Cohen & Wills, 1985). Peer support refers to the belief that colleagues provide task-related or emotional support (Thoits, 1985). According to the Job Demand-Control-Support (JDCS) model (Johnson & Hall, 1988; Karasek & Theorell, 1990), job demands, job control, and social support are key determinants of job stress. High demands combined with low control heighten stress, while strong social support can buffer these effects and enhance well-being. Peer support is especially salient in fire service culture, where colleagues with shared experiences often serve as each other’s primary source of support following critical incidents (Isaac & Buchanan, 2021). This aligns with the Interpersonal Theory of Suicide (Joiner, 2005), which identifies perceived burdensomeness and thwarted belongingness as critical precursors to suicidal ideation. Peer support may reduce these risks by fostering connectedness, reducing isolation, and providing emotional validation. Supporting this, Hom et al. (2015) found that the combination of low connectedness, high burdensomeness, and high fearlessness about death was associated with suicide attempts among firefighters.

Based on this framework, we hypothesise that peer support facilitates psychological recovery following the death of a colleague. Prior studies have shown that peer support is positively correlated with firefighters’ quality of life and reduced PTSD symptoms (Bae, 2010; Lee & Jung, 2018), and may aid in processing traumatic experiences (Donovan, 2022). Organisational factors also matter; a positive climate moderates the relationship between trauma exposure and suicidal ideation among firefighters (Back et al., 2023). Moreover, environmental support can reduce feelings of isolation, guilt and facilitate seeking professional help (Sattler et al., 2014).

Based on the proposed theoretical framework, we tested a path model in which trauma exposure (i.e. experiencing the death of a colleague) influences PTSD symptoms and suicidal risk via emotional labour and alcohol-related problems, and in which peer support functions as a moderator. Specifically, we hypothesised that:

Hypothesis 1 (H1): Experiencing a colleague’s death (directly or indirectly) will be positively associated with PTSD symptoms and suicide risk among firefighters.

Hypothesis 2 (H2): Emotional labor and alcohol-related problems will sequentially mediate the association between experiencing a colleague’s death and PTSD symptoms and suicide risk.

Hypothesis 3 (H3): Peer support will moderate the direct and indirect effects of experiencing a colleague’s death on PTSD symptoms and suicide risk, such that these relationships will be attenuated among firefighters with higher perceived peer support.

2. Methods

2.1. Participants

This nationwide cross-sectional survey, conducted in March 2021, utilized a self-report online survey administered to all firefighting institutions in South Korea. Of 58,299 firefighters in South Korea, 53,980 (92.6%) participated in the survey. Participants completed a self-report questionnaire on their exposure to traumatic events during the preceding year, PTSD symptoms, suicide risk, emotional damage due to emotional labour, perceived support from colleagues, and their demographic and occupational characteristics. The National Fire Agency of South Korea provided an anonymized dataset. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

2.2. Measures and assessments

2.2.1. Experiencing the death of a colleague

Experience of a colleague’s death in the previous year was assessed using a self-reported measure developed by Beaton et al. (1998). This tool evaluates the types and frequency of duty-related traumatic events experienced by firefighters or emergency medical personnel in the past 12 months. This measure was not a standardised instrument, but a set of items adapted from prior research (Beaton et al., 1998) to align with the specific objectives of the current study. Exposure to a colleague’s duty-related death or suicide was assessed using two items: (1) ‘Witnessed a colleague’s line-of-duty death or suicide’ and (2) ‘Experienced a colleague’s duty-related death or suicide that was not witnessed (learned about it after the fact)’ It was explicitly stated that the events referred to incidents that could be experienced in the field while performing duties, thereby excluding deaths unrelated to duty (e.g. death from cancer). ‘Direct’ exposure was defined as personally witnessing the death, while ‘indirect’ exposure referred to becoming aware of the death without direct observation. For the analysis, participants who responded ‘yes’ to either item were classified as having experienced a colleague’s death. The variable was treated as binary (0 = no experience; 1 = direct and/or indirect experience of a colleague’s death).

2.2.2. PTSD symptoms

PTSD symptoms were assessed using the Korean version of the PTSD Checklist (PCL-5) from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (Blevins et al., 2015). The PCL-5 is a validated 20-item self-report questionnaire that measures the extent to which an individual has experienced DSM-5 PTSD symptoms, such as intrusions, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity in the past month. Each item is rated on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). Higher scores indicated greater severity of PTSD symptoms. The total score was used for analysis; the higher the score, the more severe the PTSD symptoms. Total scores range from 0 to 80. Cronbach’s α was .95 in Lee et al. (2017) and .97 in the present study.

2.2.3. Suicide risk

Suicide risk was assessed using the Suicidal Behavior Questionnaire-Revised (SBQ-R; Osman et al., 2001). The SBQ-R is a widely used, validated 4-item self-report tool to identify individuals at risk of suicide. It included questions related to lifetime suicidal ideation and attempts, frequency of suicidal ideation over the past year, threats or self-harming behaviours, and the likelihood of future suicide attempts. Each question is scored on a different scale ranging from 3 to 6 points. The total SBQ-R score ranged from 3 to 18, with higher scores indicating a greater risk of suicidal behaviour. For non-clinical samples, the most appropriate total cutoff score for the identification of individuals with a high risk of suicidal behaviour based on the SBQ-R was reported as 7 (Osman et al., 2001). Total scores were used in the analysis. Cronbach’s α was .72 in Lee and Kwon (2009) and .81 in our study, indicating good internal consistency.

2.2.4. Alcohol-related problems

The Alcohol Use Disorder Identification Test was used to identify alcohol-related problems (AUDIT; Lee et al., 2000; Saunders et al., 1993). This is a widely used screening tool developed by the World Health Organization to identify individuals at risk of excessive or hazardous alcohol consumption. The Korean version of the AUDIT (AUDIT-K) demonstrated good internal consistency (Cronbach’s α = .88) and concurrent validity with other alcohol-related measures in a Korean sample (Lee et al., 2000). It evaluates frequency and quantity of alcohol intake, symptoms of dependence, and adverse effects of alcohol use. Total scores were used in the analysis. Higher scores indicate a greater risk of alcohol-related problems. The AUDIT consists of 10 items, each scored from 0 to 4, with the total score ranging from 0 to 40. The AUDIT-K has shown reliability and validity in Korean populations (Lee et al., 2000) with Cronbach's α of .92 and .84 in the present study.

2.2.5. Emotional damage due to emotional labour

The Korean Emotional Labor Scale developed by the Korea Occupational Safety and Health Agency (K-ELS; Chang et al., 2013), was used to assess emotional labour. K-ELS was developed by Korean Occupational Safety and Health Agency (Chang et al., 2013) and is widely used for occupational emotional labour assessment. Although the K-ELS consists of five subscales, this study focused exclusively on the ‘Emotional Damage due to Emotional Labor (e.g. When I hide my emotions and cannot express them while interacting with clients or 119 service recipients, I feel emotionally harmed)’ subscale. This item uses a 4-point Likert scale ranging from 1 (not at all) to 4 (absolutely). Higher scores indicate increased levels of emotional damage due to emotional labour. The total score ranges from 6 to 24. The internal consistency coefficient for this subscale was .96.

2.2.6. Perceived support from colleagues

The Perceived Social Support Scale was used to assess perceived levels of emotional support from colleagues at work (PSS; Baruch-Feldman et al., 2002). To focus on practical support received from colleagues, only five of the original seven PSS items were used (e.g. ‘My coworkers care about me’), excluding two items that were less relevant to practical support based on face validity. The items used in this scale were adopted from the 2nd Survey on the Perceptions of COVID-19 Treatment and Quarantine Personnel in Gyeonggi-do (2020) conducted by the Gyeonggi Public Health Policy Institute in South Korea. Higher scores indicated a higher level of perceived support from colleagues. The scale consists of five items rated on a 5-point Likert scale ranging from 1 (not at all) to 5 (very much). The total score ranges from 5 to 25. The internal consistency coefficient of the scale used in this study was .98.

2.3. Statistical analysis

Descriptive statistics were used to summarise the demographic, occupational, and clinical characteristics of participants. Data were analyzed using IBM SPSS Statistics (version 21.0; IBM Corp., Armonk, NY, USA) and PROCESS macro version 4.3 for SPSS (Hayes, 2022). We employed Hayes’ PROCESS Model 88, a moderated serial mediation model with one independent variable (IV), two sequential mediators, and one moderator. The IV was exposure to a colleague’s death (yes/no), and the mediators were emotional damage due to emotional labour and alcohol-related problems, forming the path: colleague’s death → emotional damage due to emotional labour → alcohol-related problems → outcomes. Two dependent variables (DVs)-PTSD symptom severity and suicide risk-were examined in separate models. Perceived support from colleagues was modelled as a moderator on the mediator-to-outcome paths only.

All continuous variables involved in interaction were mean-centered to reduce multicollinearity. Variance inflation factors (VIFs) for all predictors, including the IV, mediators, and moderator, were below 2, indicating no multicollinearity concerns. Regression assumptions were met: residuals were symmetrically distributed with no severe skew, and residual plots showed no heteroscedasticity. Given the large sample size and use of bootstrapping, minor deviations from normality were not considered problematic. No assumption violations were detected, and no additional covariates were included aside from demographic variables, where applicable.

The moderated mediation model hypothesised that experiencing the death of a colleague would sequentially affect the mediators, which in turn would impact the outcomes of suicide risk and PTSD symptoms. Moreover, it was posited that support from colleagues would moderate the effects of the mediators on the outcomes by the pathways from emotional damage due to emotional labour to the dependent variables and from alcohol-related problems to the dependent variables. In Step 1, the independent variable (colleague’s death) was entered to assess its direct effect on the outcome. In Step 2, mediators (emotional damage due to emotional labour and alcohol-related problems) were added to examine indirect effects and changes in explained variance. In Step 3, peer support and the interaction terms (peer support × emotional damage due to emotional labour; peer support × alcohol-related problems) were included to test moderation effects and evaluate whether they improved model fit and explained additional variance in PTSD and suicide risk.

Bootstrapping, a robust nonparametric resampling technique, was used to assess the indirect effects within this moderated mediation framework. This approach, used by Hayes (2022), does not assume a normal data distribution. We drew 10,000 bootstrap samples to compute 95% confidence intervals (CIs) for the indirect effects. The mediation effect was considered statistically significant if the confidence interval did not include a zero. We set the threshold for statistical significance at a two-tailed p-value of < .001.

To summarise, descriptive analyses and correlations were computed using SPSS. Subsequently, a moderated serial mediation analysis was conducted using PROCESS Model 88 (Hayes, 2022), with hierarchical regressions conducted as supplementary analyses to assess incremental variance and effect sizes. PROCESS Model 88 was chosen due to its capability to simultaneously evaluate moderated serial mediation effects consistent with our theoretical frameworks (i.e. stress-coping and JDCS models). Hierarchical regressions provided supplementary quantitative assessments of incremental variance explained by each variable added, clearly reflecting their explanatory contribution.

3. Results

3.1. Demographic, occupational, and clinical characteristics

The demographic, occupational, and clinical characteristics of the participants are presented in Table 1. The mean age of the 53,978 participants was 39.39 (standard deviation [SD] = 9.67) years. Among them, 49,089 (90.9%) were men. The average length of work was 11.46 (SD = 9.83) years. There were 1,211 participants (2.2%) who experienced a colleague’s death directly, and 4,143 (7.7%) who experienced it indirectly. Among them, 688 (1.3%) had both direct and indirect experience. A total of 4,666 participants (8.6%) experienced the death of a colleague, either directly or indirectly, at least once in the preceding year. Firefighters who experienced a colleague’s death reported significantly higher PTSD symptom scores (M = 8.34) than those who did not (M = 4.27; p < .001; Cohen’s d = 0.43), indicating a medium effect. They also reported higher suicide risk scores (M = 3.88 vs 3.45; p < .001; Cohen’s d = 0.32), reflecting a small effect. These differences underscore the psychological impact of such exposure.

Table 1.

Demographic and clinical characteristics of participants (n = 53,978).

Characteristic Participants
Age (years), mean (SD) 39.39 (9.67)
Sex (men), N (%) 49,089 (90.9)
Work lengths (years), mean (SD) 11.46 (9.83)
Direct experience of colleague’s death, N (%) 1,211 (2.2)
Indirect experience of colleague’s death, N (%) 4,143 (7.7)
PCL-5, mean (SD) 4.62 (9.43)
SBQ-R, mean (SD) 3.48 (1.34)
AUDIT, mean (SD) 5.42 (5.27)
ED, mean (SD) 10.03 (4.86)
PSS, mean (SD) 19.19 (4.29)
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Abbreviations: AUDIT, Alcohol Use Disorders Identification Test; ED, Emotional Damage due to Emotional Labor; PCL-5, Post-traumatic Stress Disorders Symptoms Checklist-5; PSS, Perceived Social Support; SBQ-R, Suicidal Behaviors Questionnaire-Revised; SD, standard deviation.

Correlations among variables are presented in Table 2. All were significantly correlated (p < .001). Direct and indirect exposure to a colleague’s death, PTSD symptoms (PCL), suicide risk (SBQ), alcohol-related problems (AUDIT), and emotional damage due to emotional labour (ED) were positively correlated, suggesting that these psychological stressors tend to co-occur. In contrast, peer support (PSS) was negatively correlated with all other variables, indicating that higher peer support is associated with lower psychological distress.

Table 2.

Correlation between variables (n = 53,978).

  1 2 3 4 5 6 7
1. Direct experience of colleague’s death 1            
2. Indirect experience of colleague’s death .172*** 1          
3. PCL-5 .075*** .108*** 1        
4. SBQ-R .048*** .074*** .466*** 1      
5. AUDIT .030*** .054*** .206*** .218*** 1    
6. ED .025*** .067*** .330*** .240*** .175 1  
7. PSS −.017*** −.033*** −.238*** −.169*** −.058*** −.192*** 1
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Note: ***p < .001, Abbreviations: AUDIT, Alcohol Use Disorders Identification Test; ED, Emotional Damage due to Emotional Labor; PCL-5, Post-traumatic Stress Disorders Symptoms Checklist-5; PSS, Perceived Social Support; SBQ-R, Suicidal Behaviors Questionnaire-Revised.

3.2. Serial mediation of emotional damage due to emotional labour, alcohol-related problems, and moderating effect of perceived support from colleagues on PTSD symptoms

To validate the proposed model, a three-stage regression analysis was conducted, after adjusting for age and sex. Figure 1 illustrates the moderated serial mediation model, in which emotional damage due to emotional labour and alcohol-related problems mediate the association between a colleague’s death and PTSD symptoms, while peer support moderates the mediator-to-outcome paths. The results presented in Table 3 and Figure 1 are summarised as follows:

  • First stage: The impact of a colleague’s death on emotional damage due to emotional labour was statistically significant, F(3, 53974) = 432.96, p < .001, indicating a direct positive effect (b = 1.31, SE = .07, t = 17.78, p < .001).

  • Second stage: We assessed the combined influence of the death of a colleague and the emotional damage due to emotional labour on alcohol-related problems. The regression model was significant, F (4, 53973) = 735.84, p < .001. A colleague’s death (b = 1.09, SE = .08, t = 13.76, p < .001) and emotional damage due to emotional labour (b = .20, SE = .005, t = 43.93, p < .001) positively influenced alcohol-related problems.

  • Third stage: We examined the combined effect of the death of a colleague, emotional damage due to emotional labour, alcohol-related problems, and peer support on PTSD symptoms. The encompassing regression model, including the independent variables, mediators, moderators, and dependent variable, was statistically significant (F (8, 53969) = 1476.03, p < .001). The death of a colleague positively influenced PTSD symptoms (b = 2.75, SE = .13, t = 20.87, p < .001). Significant positive impact was also observed through emotional damage due to emotional labour (b = 1.08, SE = .04, t = 29.88, p < .001) and through alcohol-related problems (b = .64, SE = .03, t = 21.23, p < .001). In contrast, interaction effects between emotional damage due to emotional labour and perceived support from colleagues (b = −.03, SE = .002, t = −16.29, p < .001), and between alcohol-related problems and perceived support from colleagues (b = −.02, SE = .002, t = −13.03, p < .001) negatively affected PTSD symptoms. The upper panels of Figure 2 illustrate that PTSD symptoms were higher among those with low peer support under high emotional damage due to emotional labour or alcohol-related problems, whereas high peer support buffered these effects. In summary, emotional damage due to emotional labour and alcohol-related problems mediated the relationship between experiencing a colleague’s death and PTSD symptoms, with support from colleagues playing a negative moderating role.

Figure 1.

Figure 1.

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Relationship between death of colleague and PTSD symptoms/suicide risk: mediating effects of emotional damage due to emotional labour and alcohol-related problems, and moderating effect of peer support.

Note. ***p≤.001

Table 3.

Serial mediation of emotional damage due to emotional labour and alcohol-related problems and the moderating effect of peer support on the association between the death of a colleague and PTSD symptoms.

Dependent variable Independent variable b SE t F R2
Emotional damage Age −.0006 .002 −.026 432.96*** .02
Sex 2.25 .07 30.83***
Death of Colleague 1.31 .07 17.78***
Alcohol- related problem Age −.04 .002 −15.74*** 735.84*** .05
Sex −2.38 .08 −30.24***
Death of colleague 1.09 .08 13.76***
Emotional Damage .20 .005 43.93***
PTSD symptoms Age .04 .004 9.25*** 1476.03*** .18
Sex .59 .13 4.50***
Death of Colleague 2.75 .13 20.87***
Emotional Damage 1.08 .04 29.88***
Alcohol-related Problem .64 .03 21.23***
Perceived Support from peers −.01 .02 −.58
Interaction 1 −.03 .002 −16.29***
Interaction 2 −.02 .002 −13.03***
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Note: **p < .01, ***p < .001, b = unstandardized regression coefficient, Interaction 1 = Emotional damage due to emotional labour × Perceived support from Peers, Interaction 2 = Alcohol-related problem × Perceived support from Peers. PTSD = post-traumatic stress disorder; SE = standard error; Emotional Damage = Emotional damage due to emotional labour.

Figure 2.

Figure 2.

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Interaction of emotional damage due to emotional labour or alcohol related problems and perceived support from colleagues on PTSD symptoms severity/suicide risk scores.

3.3. Indirect effects and statistical significance

The direct effect refers to the association between the experience of a colleague’s death and the outcome variable (PTSD symptoms or suicide risk) without accounting for mediators, whereas an indirect effect refers to the portion of the effect that is transmitted through a mediator variable.

The direct effect (the effect of colleague’s death on PTSD symptoms without mediators) was b = 2.75, p < .001. Bootstrapping (sample size = 10,000; Hayes, 2022) was used to assess the indirect effects (effects through mediators), with significance determined by the non-inclusion of zero within the 95% CIs (Shrout & Bolger, 2002). In this context, an ‘indirect effect’ refers to the portion of the effect of the independent variable that is transmitted through a mediator variable. The results highlight the significant conditional indirect effects of a colleague’s death on PTSD symptoms: (a) through emotional damage due to emotional labour (Effect: –.0407; 95% CI: [−.0503, –.0318]), (b) through alcohol-related problems (Effect: –.0228; 95% CI: [−.0305, –.0160]), (c) through the sequential mediation pathway (colleague’s death → emotional damage due to emotional labour → alcohol-related problems → PTSD symptoms) (Effect: –.0056; 95% CI: [−.0073, –.0040]). These indirect effects remained significant even after accounting for the direct effect of a colleague’s death on PTSD symptoms (b = 2.75, p < .001), indicating contributions from both direct and indirect pathways. The sequential mediation effect, though smaller in magnitude, was significant, supporting a cascade from emotional labour-related distress to alcohol-related problems to PTSD symptoms. These results underscore the multiple pathways through which traumatic exposure may contribute to PTSD symptoms. Figure 1 presents the conceptual model, including sequential mediation and moderation. The full model explained 18% of the variance in PTSD symptoms (R² = .18), indicating a medium effect size.

3.4. Serial mediation of emotional damage due to emotional labour, alcohol-related problems, and moderating effect of perceived support from colleagues on suicide risk

To validate the proposed model, a three-stage regression analysis was conducted, after adjusting for age and sex. Figure 1 illustrates the hypothesised serial mediation model, in which emotional damage due to emotional labour and alcohol-related problems mediate the effect of a colleague’s death on suicide risk, and peer support moderates these paths. The results presented in Table 4 and Figure 1 are summarised as follows.

  • First stage: We focused on the impact of a colleague’s death on the emotional damage due to emotional labour. The analysis revealed significant effects, F (3, 53974) = 432.96, p < .001, with a positive relationship between a colleague’s death and emotional damage due to emotional labour (b = 1.31, SE = .07, t = 17.78, p < .001).

  • Second stage: The influence of the death of a colleague and emotional damage due to emotional labour on alcohol-related problems was evaluated, showing that the model was significant, F (4, 53973) = 735.84, p < .001. The findings indicated positive effects of both the death of a colleague (b = 1.09, SE = .08, t = 13.76, p < .001) and emotional damage due to emotional labour (b = .20, SE = .005, t = 43.93, p < .001) on alcohol-related problems.

  • Third stage: We assessed the comprehensive model incorporating the death of a colleague, emotional damage due to emotional labour, alcohol-related problems, and perceived support from colleagues for suicide risk. The model was statistically significant F (8, 53969) = 1009.03, p < .001. The death of a colleague was significantly associated with suicide risk (b = .26, SE = .02, t = 13.56, p < .001). Similarly, significant positive effects were found via emotional damage due to emotional labour (b = .13, SE = .005, t = 24.16, p < .001) and alcohol-related problems (b = .11, SE = .004, t = 25.72, p < .001). In contrast, peer support (b = −.02, SE = .003, t = −6.98, p < .001) and its interaction with emotional damage due to emotional labour (b = −.004, SE = .0003, t = −15.84, p < .001) and alcohol-related problems (b = −.004, SE = .0002, t = −15.42, p < .001) had a protective effect against suicide risk. The lower panels of Figure 2 show that suicide risk increased more steeply under high emotional damage due to emotional labour and alcohol-related problems when peer support was low, whereas higher peer support buffered this increase.

Table 4.

Serial mediation of emotional damage due to emotional labour and alcohol-related problems and the moderating effect of peer support on the association between the death of a colleague and suicidal behaviour.

Dependent variable Independent variable B SE t F R2
Emotional damage Age −.0006 .002 −.26 432.96*** .02
Sex 2.25 .07 30.83***
Death of Colleague 1.31 .07 17.78***
Alcohol-related problem Age −.04 .002 −15.74*** 735.84*** .05
Sex −2.38 .08 −30.24***
Death of Colleague 1.09 .08 13.76***
Emotional Damage .20 .005 43.93***
Suicidal behaviour Age .01 .0006 18.11*** 1009.03*** .13
Sex .41 .02 21.28***
Death of Colleague .26 .02 13.56***
Emotional Damage .13 .005 24.16***
Alcohol-related Problem .11 .004 25.72***
Perceived Support from Peers −.02 .003 6.98***
Interaction 1 −.004 .0003 −15.84***
Interaction 2 −.004 .0002 −15.42***
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Note: **p < .01, ***p < .001, b = unstandardized regression coefficient, Interaction 1 = Emotional Damage due to Emotional Labour × Perceived Support from Peers, Interaction 2 = Alcohol-related Problem × Perceived Support from Peers. SE = standard error; Emotional Damage = Emotional damage due to emotional labour.

In summary, the relationship between the death of a colleague and suicide risk was mediated by both emotional damage due to emotional labour and alcohol-related problems, and the negative moderating effect of perceived support from colleagues was confirmed.

3.5. Indirect effects and statistical significance

The direct effect of a colleague’s death on suicide risk was significant (b = .26, p < .001). Significant conditional indirect effects were observed via (a) emotional damage due to emotional labour (Effect: –.0058; 95% CI: [−.0072, –.0044]), (b) alcohol-related problems (Effect: –.0039; 95% CI: [−.0053, –.0028]), and (c) the sequential pathway (colleague’s death → emotional damage due to emotional labour → alcohol-related problems → suicide risk) (Effect: –.0010; 95% CI: [−.0013, –.0007]). These effects remained significant after accounting for the direct effect, indicating that both direct and indirect pathways contribute to suicide risk. Although smaller in magnitude, the sequential mediation supports a cascade from emotional damage due to emotional labour to alcohol-related problems to increased suicide risk. This underscores the complex interplay between workplace experiences, individual emotional responses, and coping mechanisms in predicting suicide risk. Figure 1 presents the conceptual model, illustrating the sequential mediation and moderation pathways. The full model explained 13% of the variance in suicide risk (R² = .13), reflecting a medium effect size.

4. Discussion

This study examined the intricate relationship between the traumatic experience of a colleague’s death and its impact on emotional damage due to emotional labour, alcohol-related problems, PTSD symptoms, and suicide risk, as well as the moderating role of peer support. Using the death of a colleague as the primary independent variable, we investigated its direct effects on PTSD symptoms and suicide risk, and its indirect effects through emotional damage and alcohol-related problems, with peer support as a moderator.

A key finding was the sequential mediating effect of emotional damage and alcohol-related problems in the relationship between a colleague’s death and mental health outcomes. Firefighters exposed to such loss reported greater PTSD symptom severity and suicide risk, partially explained by increased emotional damage and subsequent alcohol-related problems. This pathway suggests that traumatic loss can increase emotional damage at work, which may be managed maladaptively through alcohol use.

Although this study adopted a trauma-to-symptom conceptual model based on stress-coping theory and the JDCS framework, alternative explanations are possible. For instance, firefighters with preexisting PTSD symptoms may perceive greater emotional labour demands. Suicidal ideation may also reduce engagement with peer support. Alcohol-related problems could precede and exacerbate emotional damage, particularly when alcohol drinking disrupts work functioning or workplace relationships. PTSD symptoms may independently contribute to alcohol misuse rather than through emotional damage. While alternative models were considered, the present model was selected based on theoretical rationale and prior evidence emphasising trauma-driven responses among firefighters. Future longitudinal or cross-lagged designs are needed to test potential reverse or bidirectional effects.

Previous studies have emphasised the higher prevalence and vulnerability to PTSD symptoms, suicide risk, depression, and alcohol-related problems among firefighters than those among the general population. However, few studies have examined the specific psychological impact of losing a colleague. Survivor’s guilt, an unmeasured psychological factor in this study, may contribute to these outcomes. Jonsson and Segesten (2004) found that paramedics often experience guilt and shame from perceived failure to save others, leading to internalised distress and diminished self-worth. Among firefighters, this guilt may intensify emotional burden, increase alcohol use as a means of escape, and exacerbate PTSD symptoms. Future studies should include survivor’s guilt and other moral injury-related constructs to clarify post-loss mental health trajectories among firefighters.

Previous research suggests that paramedics manage repeated trauma by concentrating on the cognitive aspects of their duties (Regehr et al., 2002). While this coping pattern pertains to paramedics, it offers insight into trauma responses in related emergency professions. In our sample, some firefighters were also cross-trained as paramedics. However, even among these individuals, repeated exposure to the deaths of close colleagues may elicit existential anxiety and erode psychological defenses (Yoon, 2023). This study is among the first to explore direct and indirect experiences of colleague deaths and their psychological consequences in firefighters, highlighting the importance of regular screening and interventions targeting emotional damage and alcohol-related problems.

Our results also demonstrate that peer support moderates the impact of a colleague’s death on PTSD symptoms and suicide risk. Specifically, higher levels of peer support reduced the adverse effects of emotional damage and alcohol-related problems on PTSD symptoms and suicide risk. These findings align with prior research suggesting that social support, particularly from peers, buffers the psychological effects of trauma. Activating intra-organisational peer support systems with fire departments may be crucial.

Intervention programmes should incorporate education about PTSD and alcohol-related problems while fostering a supportive organisational culture. Self-help groups such as Alcoholics Anonymous, 12-step programmes, and SMART Recovery have shown efficacy in addressing alcohol misuse (Humphreys & Moos, 2001, 2007; Kelly, 2022; Kelly et al., 2023). Tailored versions for firefighters could integrate emotional labour management, psychoeducation, peer support, and structured coping skills.

Programmes aimed at reducing stigma around PTSD and alcohol-related problems, with efforts to improve organisational culture, may be especially beneficial. Although many firefighters recognise that drinking more than 10 days per month or more than three drinks at a time exceeds public health standards, over half believe that intoxication is acceptable under certain circumstances (Haddock et al., 2022). Given the mediating role of alcohol-related problems in trauma outcomes, interventions should address alcohol use directly. Departments could incorporate alcohol education into mental health initiatives by training peer supporters to identify problematic drinking and provide nonjudgemental support or referrals. Clear education on healthy drinking standards and the risks of working under the influence is also critical to protect both firefighters and the community they serve. Creating alcohol-free social activities and ensuring confidentiality for those seeking help for addiction may further reduce reliance on alcohol as a coping mechanism (Holland-Winkler et al., 2023).

Fire departments could institutionalise structural postvention protocols, including peer support teams, memorial activities, and access to professional counselling to promote adaptive grieving. Formal peer networks with trained responders available after traumatic incidents may help reduce PTSD symptoms and suicidal risk. Ensuring these services are accessible and culturally accepted within firefighters communities is essential to overcoming stigma (Isaac & Buchanan, 2021).

Our findings, also highlight the role of coping strategies. Research by Folkman et al. (1986) distinguishes between emotion-focused (e.g. venting suppression) and problem-focused coping (e.g. addressing the issue directly). Although we did not directly assess coping style, the partial effect of peer support and the mediating role of alcohol use suggest a need to promote more adaptive coping strategies. Firefighters may initially rely on emotion-focused coping, such as venting or alcohol use, which can burden support systems. Chang (2018) noted that excessive emotional venting or prolonged dependence on peer support may burden support networks, especially in close-knit teams. In contrast, encouraging problem-focused coping – through help-seeking, counselling, and structured peer support programmes – may support better psychological outcomes.

Psychotherapy after trauma often shifts coping from emotion- to problem-focused, optimising external support and internal growth. Additionally, strengthening peer support and open communication can help shift firefighters from emotion-focused coping into problem-focused strategies, consistent with our finding that peer support mitigates negative outcomes (Barry et al., 2023; Folkman et al., 1986).

Therapeutic approaches in PTSD treatment such as Seeking Safety Treatment (Najavits, 2002), Complicated Grief Therapy (Neimeyer & Burke, 2012), and Dialectical Behavior Therapy (Wagner & Linehan, 2006) emphasise non-stigmatizing, supportive environments and recognise substance use as a response to trauma. Therapeutic approaches also acknowledge the role of substance use as a means to cope with or ‘numb’ pain (Najavits, 2002). Integrating basic group education on PTSD and substance use may help firefighters reframe symptoms as shared challenges rather than problems to be hidden or stigmatised. This reframing can strengthen organisational culture by promoting understanding of symptoms as ‘functions’ that need to be addressed, not as ‘problems’ to be feared or ignored, thereby supporting healthier, collective coping.

Camaraderie is central in fire service culture, underscoring the value of peer-led programmes. Peer support enhances empathy and understanding based on their shared experiences, and can increase motivation to seek help (Mead et al., 2001). The Buddy-to-Buddy programme, for example, has been shown to reduce social stigma and psychological symptoms among public safety personnel (Greden et al., 2010). A Korean programme by Hur and Jung (2022) demonstrated improved empathy and self-reflection among firefighters participants. Based on such findings, fire departments should consider implementing or expanding peer support training and peer counselling teams as part of their intervention efforts. In particular, group counselling to address grief after colleague loss may further reinforce support networks.

Despite an increase in the use of the National Fire Agency’s counselling services in South Korea, awareness and acknowledgment of the need for counselling remain limited. Promoting understanding and visibility of such services is essential for supporting firefighters mental health and resilience.

4.1. Limitations

The limitations of this study and suggestions for future research are as follows.

  • First, this study relied on self-reported surveys conducted by the National Fire Agency. Given the intra-organisational context, responses may have been influenced by social desirability, potentially leading to symptom underreporting.

  • Second, although the questionnaire focused on duty-related deaths likely to be sudden or traumatic, we could not independently verify whether each event met DSM-5 Criterion A for PTSD. Future studies should employ more precise classification methods.

  • Third, participants were asked to report all potentially traumatic events from the past year without specifying the timing of each. Some events may have occurred within the prior month, thus falling under the diagnostic window for acute stress disorder rather than PTSD. As these conditions differ in prognosis and course, results should be interpreted with caution.

  • Fourth, due to the cross-sectional design, causality inferences cannot be made. Observed associations may reflect bidirectional or reversed effects. Longitudinal studies are needed to clarify directionality.

  • Fifth, this study included only currently employed South Korean firefighters without controlling for those undergoing counselling or pharmacological treatment. These variables may influence PTSD and suicide risk and should be considered in future research.

  • Sixth, while the mediating roles of emotional damage due to emotional labour and alcohol-related problems were statistically significant, effect sizes were small, suggesting other unmeasured mediators – such as resilience, social resources, or comorbid conditions – may be involved.

  • Seventh, the large sample size may have contributed to statistically significant findings with small effects. Practical implications should thus be interpreted cautiously.

  • Eighth, peer support was measured using a modified version of the Perceived Social Support Scale (PSS), with two items removed for contextual relevance. While based on a previous public health survey, this adaptation lacks broad psychometric validation, warranting further evaluation.

Despite these limitations, to our knowledge, this is among the first studies to specifically examine the compounded effect of experiencing a colleague’s death (both direct and indirect) on PTSD symptoms and suicide risk in firefighters using a large nationwide sample. Its significance is further highlighted by the inclusion of data from 92.6% South Korean firefighters. We hope that our findings contribute to a deeper understanding of the mental health challenges faced by firefighters and encourage the development of improved policies and interventions to support their psychological well-being.

Acknowledgements

We would like to thank all the firefighters who save people in South Korea.

Funding Statement

This work was supported by the National Fire Agency Research Fund 2021.

Consent to participate

The data used in this study was provided by the National Fire Agency in an anonymized format. Therefore, the consent of the study participants was exempted by the Institutional Review Board (IRB).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data supporting the findings of this study are unavailable because they belong to the National Fire Agency.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data supporting the findings of this study are unavailable because they belong to the National Fire Agency.

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