Silent crisis on the frontlines: a systematic review of suicidal behaviors among disaster responders – epidemiology, risk pathways, and evidence-based interventions

Abstract

Background

First responders (including paramedics, firefighters, police, and dispatchers) experience significantly elevated suicide risk due to repeated trauma exposure, high rates of PTSD and depression, and systemic barriers to mental healthcare. This systematic review examines (1) suicide prevalence, (2) psychological and occupational risk factors, and (3) interventions across different emergency service roles and global contexts.

Method

This study rigorously adhered to the PRISMA guidelines in conducting a systematic and comprehensive analysis of 24 peer-reviewed studies (up to February 2025), meticulously sourced from PubMed, Scopus, Web of Science, and Embase. Only studies providing unique qualitative or quantitative insights into Suicidal Behaviors Among Disaster Responders were included. The extracted data was meticulously examined using advanced thematic analysis and robust descriptive statistics, ensuring a deep, evidence-based exploration of this critical issue.

Results

The systematic analysis of 24 studies revealed four critical categories shaping suicidal behaviors among disaster responders: (1) Epidemiology and Prevalence, highlighting elevated risks in firefighters and EMS personnel; (2) Psychological and Occupational Risk Factors, including PTSD, depression, and workplace burnout; (3) Systemic and Cultural Barriers, such as stigma and rural access gaps; and (4) Interventions and Solutions, demonstrating efficacy in trauma-focused therapies, peer support, and policy reforms like Houston’s zero-suicide program. Thematic synthesis underscored the interplay of individual vulnerabilities and structural failures, urging integrated, occupation-specific prevention strategies.

Conclusion

Effective prevention requires integrated clinical interventions (trauma-focused therapies), organizational reforms (routine screenings), and cultural shifts (destigmatization).

Introduction

First responders—including firefighters, emergency medical services (EMS) personnel, police officers, and dispatchers—routinely confront life-threatening situations, traumatic events, and prolonged occupational stress, placing them at heightened risk for mental health disorders and suicidal behaviors [1]. Despite their critical role in public safety, these populations face a silent crisis: suicide rates among first responders far exceed those of the general population, with career firefighters reporting lifetime suicidal ideation rates as high as 46.8% and EMS personnel exhibiting a suicide risk tenfold higher than civilians [2]. The compounding effects of cumulative trauma exposure, organizational stigma, and inadequate mental health resources create a perfect storm of vulnerability, yet systematic efforts to synthesize the epidemiological patterns, psychological mechanisms, and evidence-based interventions remain fragmented.

The existing literature highlights alarming trends, such as the pervasive role of post-traumatic stress disorder (PTSD), depression, and hazardous alcohol use in mediating suicide risk, as well as occupational stressors like shift work, emotional labor, and a culture of stoicism that discourages help-seeking [3]. For instance, studies report PTSD prevalence rates of 18–33% among first responders, with re-experiencing symptoms strongly correlating with suicidal ideation [1, 4]. Workplace factors further exacerbate risk, including bullying, burnout, and disparities in access to mental health care—particularly for rural responders, women, and minorities, who are often underrepresented in research [5]. Protective factors, such as peer support and resilience training, show promise but are inconsistently implemented due to systemic barriers like stigma, funding gaps, and a lack of standardized protocols [6].

While prior reviews have examined discrete aspects of this issue—such as PTSD outcomes or workplace interventions—none have comprehensively integrated the epidemiological, psychological, and systemic dimensions of suicide risk across all first responder subgroups [7–9]. This gap obscures the interplay between individual vulnerabilities (e.g., anxiety sensitivity, sleep disturbances) and structural determinants (e.g., policy failures, cultural norms), hindering the development of targeted, scalable solutions. Moreover, the predominance of cross-sectional studies and self-report data limits causal inferences, while regional disparities in research focus leave low-resource and non-Western settings underexplored.

To address these limitations, this systematic review synthesizes three decades of global evidence to answer the following question: What are the prevalence rates, mechanistic pathways, and effective interventions for suicide prevention among first responders, and how do these factors vary by occupation, demographic subgroup, and geographical context? By mapping the continuum of risk—from trauma exposure to systemic failures—this review aims to inform clinical practice, organizational policies, and future research priorities to mitigate this public health emergency among those who dedicate their lives to saving others.

Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure methodological rigor and transparency [10]. The study aimed to synthesize global evidence on suicide epidemiology, risk pathways, and interventions among first responders, including firefighters, emergency medical services (EMS) personnel, police officers, and dispatchers. Initially, the search strategy was developed in accordance with PRISMA guidelines to systematically identify, screen, select, and extract relevant data from the studies. This process, along with the quality assessment of the included studies, was conducted independently by six researchers. Subsequently, a thematic content analysis was performed, which involved extracting initial codes, identifying key themes, and drafting the findings.

Search strategy

The search strategy targeted studies on suicidality and self-harming behaviors among frontline disaster workers. A systematic search was performed across four databases (PubMed, Web of Science, Scopus, and Embase) and Google Scholar. The final search was completed in February 2025 (see Table 1).

Table 1.

The search strategy of the study

Search String	Database	Results
(Suicide[mh] OR Suicide[tiab] OR Suicides[tiab]) AND (“Medical responders”[tiab] OR “first responders”[tiab] OR firefighters[tiab] OR “front line forces”[tiab] OR “rescue personnel”[tiab])	PubMed	162
(Suicide: ti, ab, kw OR Suicides: ti, ab, kw) AND (“Medical responders” :ti, ab, kw OR “first responders” :ti, ab, kw OR firefighters: ti, ab, kw OR “front line forces” :ti, ab, kw OR “rescue personnel” :ti, ab, kw)	Embase	166
TS=(Suicide OR Suicides) AND TS=(“Medical responders” OR “first responders” OR firefighters OR “front line forces” OR “rescue personnel”)	WOS	255
TITLE-ABS-KEY (Suicide OR Suicides) AND TITLE-ABS-KEY (“Medical responders” OR “first responders” OR firefighters OR “front line forces” OR “rescue personnel”)	Scopus	341

Eligibility criteria

Studies were included if they met the following criteria: (1) peer-reviewed quantitative, qualitative, or mixed-methods research addressing suicide prevalence, risk factors, or interventions in first responders; (2) published in English; and (3) provided explicit data on first responder subgroups (e.g., career vs. volunteer firefighters).

Excluded studies were those focusing solely on general populations without first responder-specific data, non-English publications, and editorials or conference abstracts lacking full-text data.

Quality assessment of included studies

The search results were imported into EndNote v.20 (Windows) for management. After removing duplicate records and articles that met the exclusion criteria, the remaining records underwent title/abstract screening to identify relevant studies. Subsequently, a full-text review of the selected articles was conducted.

Two researchers from the Department of Health in Disasters and Emergencies independently assessed the methodological quality of the included studies using the STROBE, JBI, and CASP checklists. To ensure rigor, two additional team members performed a secondary review. Finally, the articles were analyzed in depth using thematic content analysis.

Data screening process

The extracted data were analyzed using thematic analysis and descriptive statistics. Descriptive analyses categorized the articles by authors, study type, publication year, country, and key findings. Additionally, a thematic content analysis was conducted to identify core themes related to self-harming behaviors (suicide) among rescue personnel.

Inter-coder reliability and risk of bias assessment

To ensure the robustness and consistency of the thematic content analysis, inter-coder reliability was rigorously evaluated. Two independent researchers initially coded qualitative data extracted from the included studies using an inductive approach, allowing themes to emerge organically from recurrent patterns and concepts within the dataset.

A randomly selected subset comprising 20% of the coded material was used to assess inter-coder agreement. Cohen’s Kappa coefficient was calculated to quantify agreement beyond chance, yielding a value of 0.84, which reflects substantial inter-coder reliability. Minor discrepancies, which predominantly pertained to the hierarchical classification of sub-themes, were resolved through consensus discussions. In cases where agreement could not be readily reached, a third senior reviewer was consulted to ensure analytical rigor and thematic coherence.

To address potential biases and evaluate the overall strength of evidence, a qualitative assessment was conducted throughout the study appraisal and synthesis process. Although the heterogeneity of study designs and outcomes precluded formal meta-analytic statistical evaluation, the consistency of findings across studies and methodological quality were considered in interpreting the results. The GRADE framework was deliberated for its applicability but was not formally employed due to the predominantly qualitative nature of the synthesized evidence. This approach underscores the transparency and methodological integrity of the review process.

Results

The systematic search across PubMed, ProQuest, Web of Science, and Scopus initially identified 924 articles, which were reduced to 668 unique records after duplicate removal. Title and abstract screening yielded 54 potentially relevant articles, of which 14 were excluded for being unrelated to the research topic, 10 were removed as review articles, and 6 were excluded due to inadequate quality, leaving 22 eligible studies. A supplementary Google Scholar search retrieved 10 additional articles, with 2 meeting the inclusion criteria, resulting in a final selection of 24 studies for analysis. (Fig. 1).

Fig. 1.

PRISMA 2020 flow diagram of study selection for the systematic review of harmful behaviors among disaster relief workers

Descriptive statistics

A total of 24 studies, published up to February 2025, met the inclusion criteria. The geographic distribution included two studies each from Australia and South Korea, one each from Turkey and Poland, and the remaining studies (n = 18) from the United States. Key characteristics of the selected studies are presented in Table 2.

Table 2.

Characteristics of articles retrieved in a systematic review of self-harming (suicidal) behaviors among disaster responders

N	Authors	Goals	Type of Study	Year	country	Important key finding	Checklist
[1]	Rosalie S. Aldrich1 et al.	investigating the relationship between suicide exposure and depression, anxiety, and post-traumatic stress disorder (PTSD) among three occupational groups with a high likelihood of suicide exposure.	cross-sectional	2020	USA	Exposure to suicide was significantly associated with poorer mental health outcomes, particularly elevated symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD). Greater frequency or intensity of exposure correlated with increased severity of these psychological symptoms	STROBE
[2]	Shelby N. Baker et al.	This study sought to replicate and extend the Three-Step Theory of Suicide (3ST) by investigating the role of physical and psychological pain in Step 1 among first responders.	Research Trends	2025	USA	The findings corroborate the Three-Step Theory of Suicide (3ST) and underscore the significant role of physical pain in shaping suicidal desire among first responders.	STROBE
[3]	Brooke A. Bartlett et al.	This study examined the moderating role of distress tolerance (DT) in the relationship between posttraumatic stress disorder (PTSD) symptomatology and suicidality among firefighters	Original Article	2018	USA	Firefighters exhibiting more severe PTSD symptoms coupled with lower distress tolerance (DT) demonstrated the greatest global suicide risk and highest perceived likelihood of future suicide attempts.	JBI
[4]	Joseph W. Boffa et al.	Examining the association between posttraumatic stress symptoms (PTSS) and both history of suicidal ideation (SI) and prior suicide attempts in a national sample of firefighters.	cross-sectional	2017	USA	After accounting for established suicidality risk factors, results demonstrated that elevated posttraumatic stress symptoms (PTSS) significantly predicted increased likelihood of both lifetime suicidal ideation (SI) and previous suicide attempts	STROBE
[5]	Joseph W. Boffa et al.	This study sought to replicate the mediating role of anxiety sensitivity (AS) cognitive concerns in the relationship between PTSD symptoms and suicide risk among 214 trauma-exposed male firefighters who reported non-zero suicide risk.	cross-sectional survey	2019	USA	Anxiety sensitivity (AS) cognitive concerns mediated the bidirectional relationship between PTSD symptoms (total score and symptom clusters) and suicide risk in firefighters. These findings suggest AS cognitive concerns represent a modifiable risk factor for suicidality in this population, with AS-specific interventions potentially reducing both PTSD symptoms and suicide risk	STROBE
[6]	Derrick L. Edwards et al.	Examining the association between emotional exhaustion and suicide risk among emergency responders	cross-sectional survey	2020	USA	Emergency responders reporting high emotional exhaustion demonstrated mean suicide risk scores nearing the clinically significant threshold (cut-off ≥ 7).	STROBE
[7]	Emmanuel J. Finney et al.	Assessing suicide prevalence and prevention strategies in firefighter populations	Observational descriptive multicenter study and interview	2015	USA	The HFD Suicide Prevention Program, launched in 2007, established the coordinated FAN team to address members’ mental health needs, resulting in zero active-duty suicides for five years and the prevention of at least three near-certain cases	CASP
[8]	Michael P. Fisher, et al.	This study investigates the opportunities and barriers encountered by professionals developing and implementing mental health policies and programs for first responders	Qualitative research	2023	USA	Effective mental health programs and policies for first responders remain critically needed. Governmental and non-governmental stakeholders must prioritize strategic development and implementation, informed by systematic analysis of existing challenges and opportunities	CASP
[9]	Austin J. Gallyer, B.S, et al.	The study explored alcohol use as a suicide risk factor in firefighters, testing interpersonal theory variables as potential mediators across two large samples	cross-sectional	2018	USA	Perceived burdensomeness (PB) and thwarted belongingness (TB) may mediate the alcohol use-suicidal ideation relationship, with significant gender differences observed in this mediating effect.	JBI
[10]	Nathaniel Andrew Healy	This study investigated the moderating role of global sleep disturbance and its five facets (sleep efficiency, perceived sleep quality, daily disturbances, bad dreams, and pain) in the relationship between PTSD symptom severity and suicide risk among firefighters	Analytical Cross-Sectional Study- Thesis	2020	USA	Significant interaction effects were found between PTSD symptom severity and global sleep disturbance, sleep efficiency, perceived sleep quality, and daily disturbances in relation to suicide risk.	JBI
[11]	Elizabeth Henderson et al.	Examining suicidal ideation among U.S. firefighters by integrating the Neuman Systems Model and Joiner’s Interpersonal-Psychological Theory, identifying key risk factors and informing targeted prevention strategies.	Conceptual study	2021	USA	Firefighters’ suicidal ideation stems from occupational stressors and interpersonal struggles, requiring holistic interventions that address both systemic pressures and psychological vulnerabilities.	JBI
[12]	Joseph Herzog et al.	Examining the prevalence of trauma-related mental health symptoms (PTSD, depression, anxiety, alcohol misuse, and suicidal ideation) among firefighters in a U.S. hurricane disaster zone and assess the impact of job-related natural disaster exposure on PTSD severity.	Cross-sectional survey study	2022	USA	Firefighters exposed to natural disasters during duty showed significantly higher PTSD symptoms, with 18.9% meeting provisional PTSD criteria, highlighting occupational trauma as a critical mental health risk factor in this population.	STORBE
[13]	Johanna Inhyang Kim et al.	This study aimed to investigate whether alcohol use disorders (AUDs) and insomnia mediate the relationship between PTSD symptoms and suicidal ideation among Korean firefighters, using a cross-sectional design to explore these interconnected mental health risks.	Cross-sectional survey study	2018	South Korea	The study revealed that AUDs and insomnia partially mediate the association between PTSD symptoms and suicidal ideation, highlighting their critical roles in exacerbating suicide risk in this high-stress occupational group.	STORBE
[14]	Michael J Kyron et al.	This study aimed to assess the prevalence and predictors of suicidal thoughts and behaviors among Australian police and emergency services employees, examining both personal (e.g., mental health, substance use) and workplace (e.g., stigma, bullying) risk factors.	Cross-sectional survey	2020	Australia	Emergency services personnel reported higher rates of suicidal thoughts and plans compared to the general Australian population, with workplace factors like bullying and stigma, as well as personal factors like PTSD and psychological distress, significantly associated with increased risk.	STORBE
[15]	Milner et al.	This study aimed to compare suicide rates among emergency and protective service workers (e.g., police, ambulance, firefighters, defense, and prison officers) to other occupations in Australia over a 12-year period (2001–2012) and analyze suicide methods.	Retrospective mortality study	2016	Australia	Emergency and protective service workers had significantly higher suicide rates than other occupations, with the highest risk observed among ambulance personnel, defense force members, and prison officers. Hanging was the most common method, except for police, who predominantly used firearms.	CASP
[16]	Heyeon Park et al.	This study aimed to measure the 1-year prevalence of suicidal ideation among Korean firefighters and investigate its correlates, including demographic, occupational, and clinical factors.	Cross-sectional survey	2019	South Korea	The 1-year prevalence of suicidal ideation among Korean firefighters was 10.66%, significantly higher than the general population. Key correlates included female gender, recent traumatic experiences, high occupational stress, emotional labor, and psychiatric symptoms like PTSD and depression.	STROBE
[17]	Renkiewicz. et al.	This cross-sectional study conducted in the United States aimed to investigate the prevalence of suicidality among Emergency Medical Services (EMS) personnel and identify key predictors, including personal trauma profiles, occupational stress, and sociodemographic factors.	Cross-sectional survey	2022	USA	The study revealed that 24.5% of EMS personnel reported lifetime suicidality, with Indigenous race, prior military service, sexual minority status, childhood emotional abuse, and burnout being significant predictors. The findings highlight the urgent need for targeted mental health interventions in this high-risk profession.	STROBE
[18]	Yücel Şavklı et al.	This cross-sectional and correlational study conducted in Türkiye aimed to examine the moderating role of resilience in the relationship between post-traumatic stress disorder (PTSD) symptoms and suicidal ideation among firefighters, addressing a gap in research on protective factors for this high-risk group.	Cross-sectional survey	2023	Türkiye	The study found that PTSD symptoms significantly increased suicidal ideation, particularly among firefighters with low resilience levels. Resilience acted as a buffer, weakening this relationship when present at moderate or high levels, underscoring the need for resilience-building interventions in psychological programs for firefighters.	STROBE
[19]	Donna et al.	This study aimed to identify distinct profiles of emotional distress, suicidality, and resilience among treatment-seeking first responders in the United States using latent profile analysis (LPA), to better understand their mental health needs and inform targeted interventions.	Cross-sectional survey	2025	USA	The LPA revealed five distinct emotional distress profiles, ranging from minimal to severe, with depression and generalized anxiety as strong predictors of class membership. Resilience moderated distress levels, highlighting the need for transdiagnostic interventions that address comorbid symptoms while enhancing resilience in this high-risk population.	STROBE
[20]	Smith	This study aimed to investigate the risk factors associated with suicidal ideation and behavior among wildland firefighters in the United States, focusing on PTSD symptoms, alcohol use, and occupational exposure to suicide.	Cross-sectional survey	2024	USA	The study found that 22% of wildland firefighters reported a history of suicide attempts, and PTSD symptoms were significantly associated with suicidal ideation and behavior, while alcohol use and suicide exposure were not.	JBA
[21]	STREEB et al.	This study examined how critical incidents, coping self-efficacy, and social support relate to suicide risk factors (thwarted belongingness, perceived burdensomeness, fearlessness about death) in firefighters, integrating IPTS and SCT frameworks.	Cross-sectional survey	2018	USA	Trauma coping self-efficacy mediated the link between critical incidents and suicide risk factors, with social support from significant others buffering this relationship.	JBA
[22]	Robin Verble et al.	This study aimed to assess mental health risks among U.S. wildland fire dispatchers, focusing on anxiety, depression, PTSD, and suicidal ideation linked to occupational trauma and job stressors.	Cross-sectional survey	2024	USA	Wildland fire dispatchers exhibited higher rates of mental health disorders (e.g., 73% depression, 32% suicidal ideation) than the general population and other emergency responders, with disparities tied to demographics and trauma exposure.	STROBE
[23]	Neil H. Vigil et al.	This study aimed to determine the proportionate mortality ratio (PMR) of suicide among firefighters and emergency medical technicians (EMTs) in the United States compared to the general working population, focusing on occupational risk factors.	Retrospective cohort study	2021	USA	Firefighters had a significantly higher PMR for suicide (172, 95% CI 153–193), especially those aged 65–90 (PMR 234), while EMTs showed elevated but non-significant PMRs (124, 95% CI 99–153).	CASP
[24]	Kinga Witczak-Błoszyk et al.	This study aimed to assess work-related suicide exposure, occupational burnout, and coping mechanisms among emergency medical services (EMS) personnel in Poland, while exploring psychosocial determinants such as age, gender, and access to psychological support.	Cross-sectional study	2022	Poland	Nearly all EMS personnel (98%) reported suicide exposure, with 43% finding it distressing. High burnout levels, particularly relational deterioration, were linked to suicide exposure, while access to psychological support reduced burnout symptoms.	STROBE

Methodological quality

Fourteen of the twenty-four articles were evaluated using the STROBE checklist, which assesses reporting quality through 22 specific items organized into standard research paper sections. The checklist evaluates the Title and Abstract (Item 1), the Introduction through background/rationale (Item 2) and objectives (Item 3), the Methods section via study design (Item 4), setting (Item 5), participants (Item 6), variables (Item 7), data sources/measurement (Item 8), bias (Item 9), study size (Item 10), quantitative variables (Item 11), and statistical methods (Item 12), the Results through participant flow (Item 13), descriptive data (Item 14), outcome data (Item 15), main results (Item 16), and other analyses (Item 17), the Discussion via key results (Item 18), limitations (Item 19), interpretation (Item 20), and generalizability (Item 21), and finally Other Information such as funding (Item 22). The complete results of this evaluation are presented in Table 3.

Table 3.

Critical appraisal of research papers

Citation	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12	Q13	Q14	Q15	Q16	Q17	Q18	Q19	Q20	Q21	Q22	Total
Rosalie S. Aldrich1 et al.	Y	Y	Y	Y	Y	Y	Y	Y	N	U	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	20/22
Shelby N. Baker et al.	Y	Y	Y	Y	N	Y	Y	Y	N	Y	Y	Y	Y	Y	Y	U	N	Y	Y	Y	Y	Y	18/22
Joseph W. Boffa et al.	Y	Y	Y	U	Y	U	Y	Y	N	N	Y	Y	Y	Y	Y	N	N	Y	Y	Y	Y	N	15/22
Joseph W. Boffa et al.	Y	Y	Y	U	N	Y	Y	Y	N	N	Y	N	Y	N	Y	Y	N	Y	Y	Y	Y	Y	15/22
Derrick L. Edwards et al.	Y	Y	Y	Y	N	Y	Y	Y	N	Y	Y	Y	N	Y	Y	Y	N	Y	Y	Y	Y	Y	18/22
Joseph Herzog et al.	Y	Y	Y	Y	Y	Y	Y	Y	N	U	Y	N	N	Y	Y	Y	N	Y	Y	Y	Y	Y	17/22
Johanna Inhyang Kim et al.	Y	Y	Y	Y	Y	NA	Y	Y	N	Y	Y	N	N	NA	Y	NA	Y	Y	Y	Y	Y	Y	16/22
Michael J Kyron et al.	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	N	Y	Y	N	Y	Y	Y	Y	Y	Y	20/22
Heyeon Park et al.	Y	Y	Y	Y	Y	N	Y	Y	N	N	Y	U	N	U	Y	NA	Y	Y	Y	Y	Y	Y	15/22
Renkiewicz. et al.	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	N	N	Y	Y	N	Y	Y	Y	Y	Y	N	18/22
Yücel Şavklı et al.	Y	Y	Y	Y	Y	Y	Y	Y	Y	N	Y	N	N	U	Y	U	Y	Y	Y	Y	Y	N	16/22
Donna et al.	Y	Y	Y	Y	Y	Y	Y	Y	Y	N	Y	N	N	Y	Y	Y	Y	Y	Y	Y	Y	Y	19/22
Robin Verble et al.	Y	Y	Y	Y	Y	Y	Y	Y	Y	N	Y	U	U	Y	Y	Y	Y	Y	Y	Y	Y	Y	19/22
Kinga Witczak-Błoszyk et al.	Y	Y	Y	Y	Y	Y	Y	Y	Y	N	Y	U	U	U	Y	Y	Y	Y	Y	Y	Y	Y	18/22

Y, yes; N, no; NA, not applicable; U, unclear

Six analytical cross-sectional studies were evaluated using the JBI Critical Appraisal Checklist, which includes the following questions: whether the criteria for inclusion in the sample were clearly defined; if the study subjects and setting were described in detail; if exposure was measured in a valid and reliable way; whether objective, standard criteria were used for measuring the condition; if confounding factors were identified; whether strategies to deal with confounding factors were stated; if outcomes were measured in a valid and reliable manner; and whether appropriate statistical analysis was used. For detailed results, see Table 4.

Table 4.

Critical appraisal of cross-sectional studies

Citation	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Total
Brooke A. Bartlett et al.	Y	Y	Y	Y	Y	Y	Y	Y	8/8
Austin J. Gallyer, B.S, et al.	Y	Y	Y	Y	Y	Y	Y	Y	8/8
Nathaniel Andrew Healy	Y	Y	Y	Y	Y	Y	Y	Y	8/8
Elizabeth Henderson et al.	Y	Y	Y	N	N	U	Y	Y	5/8
Smith	Y	Y	Y	Y	Y	Y	Y	Y	8/8
STREEB et al.	Y	Y	Y	Y	Y	Y	Y	Y	8/8

Y, yes; N, no; NA, not applicable; U, unclear

Two retrospective cohort studies were evaluated using the 12-question CASP Cohort Checklist, which scrutinizes the focus of the issue, the recruitment strategy to minimize selection bias, the accuracy of exposure and outcome measurements, the identification of confounding factors, the completeness of follow-up, and the clarity, precision, and applicability of the results. One cross-sectional observational study was assessed with the 11-question CASP Cross-Sectional Checklist, focusing on the study’s focus, methodological appropriateness, subject recruitment, accuracy of measures, data collection methods, sample size adequacy, presentation of results, analytical rigor, and the value and local applicability of the findings. Finally, one qualitative study was appraised using the 10-question CASP Qualitative Checklist, which examines the clarity of the research aims, the appropriateness of the methodology and research design, recruitment strategy, data collection methods, the researcher-participant relationship, ethical considerations, the rigor of the analysis, and the statement and value of the findings. For a detailed breakdown of the appraisal scores for each study, please refer to Table 5.

Table 5.

Critical appraisal of retrospective and qualitative studies

Y, yes; N, no; NA, not applicable; U, unclear

Thematic content analysis

The systematic review and thematic content analysis revealed a comprehensive framework for understanding self-harming (suicidal) behaviors among disaster responders, structured around four major categories, eight key themes, and sixteen sub-themes. The first category, Epidemiology and Prevalence, examines the scope and distribution of suicidal behaviors, highlighting occupational disparities such as elevated risks among specific responder groups like EMS personnel and firefighters, as well as demographic variations including gender and age-related vulnerabilities. The second category, Psychological and Occupational Risk Factors, delves into the mental health comorbidities such as PTSD, depression, and anxiety that exacerbate suicide risk, alongside occupational stressors like cumulative trauma exposure, workplace bullying, and burnout.

The third category, Systemic and Cultural Barriers, addresses the challenges hindering effective prevention, including stigma and underreporting due to fears of professional repercussions, as well as systemic gaps in resources, training, and culturally competent care. Finally, the fourth category, Interventions and Solutions, explores evidence-based clinical and peer support strategies, such as cognitive processing therapy and resilience-building programs, alongside organizational and policy reforms aimed at reducing stigma, improving access to mental health services, and implementing long-term monitoring systems. Together, these categories and their underlying themes provide a nuanced understanding of the factors influencing suicidal behaviors in disaster responders, offering actionable insights for prevention and support (see Table 6 for detailed findings).

Table 6.

The elements of self-harming (suicidal) behaviors among disaster responders, as determined by theme content analysis and systematic review

N	Category	Theme	Sub-theme	Code	References
1	Epidemiology and Prevalence	Occupational Disparities	High-Risk Groups	Firefighters: 46.8% career suicidal ideation, 15.5% attempts	[11–13]
				EMS personnel: 10× higher risk than general population	[14–16]
				Wildland firefighters: 22% suicide attempt history	[17]
				Dispatchers: 32% suicidal ideation	[18]
			Demographic Variations	Female firefighters show higher suicidality	[13, 19–21]
				Native groups: Elevated risk	[15, 22]
				Retirees: Highest suicide risk (PMR = 234)	[23]
		Trauma Exposure	Cumulative Trauma	91.5% of firefighters experience high trauma exposure	[19]
				94% dispatchers exposed to work-related trauma	[18]
				98% EMS personnel exposed to suicide scenes	[16]
			PTSD Link	PTSD prevalence: 18.9% (firefighters) (Article 12); 25.4% (wildland)	[17]
				PTSD symptoms correlate with suicide exposure	[13, 24, 25]
2	Psychological and Occupational Risk Factors	Mental Health Comorbidities	Depression/Anxiety	PHQ-9 (mean = 8.35) and GAD-7 (mean = 6.88) scores elevated	[24, 26]
				- Depression (OR = 8.92) linked to suicidal ideation	[20, 27]
			Substance Use and Sleep	Hazardous drinking: 38.8%	[26, 28]
				AUD mediates PTSD-suicide link	[25, 29]
				Insomnia mediates PTSD-suicidal ideation	[23, 25]
		Occupational Stressors	Work Culture	Culture of independence” increases risk	[12, 24, 30]
				Bullying predicts suicide plans/attempts	[31]
			Burnout	Emotional exhaustion correlates with SBQ-R scores	[15, 32]
				Burnout linked to suicide exposure (β = 0.42)	[16]
3	Systemic and Cultural Barriers	Stigma and Help-Seeking	Underreporting	Fear of job repercussions	[13, 24, 30, 33, 34]
				Male-dominated norms hinder help-seeking	[13, 14]
			Access Barriers	Rural vs. urban EAP gaps	[26, 30]
				Only 27% dispatchers comfortable discussing mental health	[18]
		Resource and Training Gaps	Training Deficits	Lack of standardized prevention programs	[24, 30]
				Need for culturally competent care	[15, 32]
			Leadership and Policy	Grassroots leadership drives programs	[30]
				Mandatory officer training (85% completion)	[34]
4	Interventions and Solutions	Clinical and Peer Support	Evidence-Based Therapies	CPT/PE reduce PTSS and suicidality	[22, 29, 34]
				Peer programs for trauma coping	[13, 16, 29]
			Early Identification	Routine mental health screenings	[20, 22]
				Screen for PTSD/alcohol abuse	[23]
		Organizational Strategies	Policy Reforms	Houston’s 3-phase program: 5-year zero suicides	[34]
				Restrict lethal means access	[14]
			Cultural Shifts	Destigmatization campaigns	[21, 22]
				Promote help-seeking	[13, 21]

Discussion

This systematic review sought to answer a critical question: What are the prevalence rates, mechanistic pathways, and effective interventions for suicide prevention among first responders, and how do these factors vary by occupation, demographic subgroup, and geographical context? The findings reveal a pervasive public health crisis, with suicide rates among first responders significantly exceeding those of the general population, driven by occupational trauma, mental health comorbidities, and systemic barriers. The synthesis of 26 studies underscores the urgency of addressing this issue through integrated, multi-level interventions that target individual vulnerabilities, organizational cultures, and policy gaps.

Epidemiology and prevalence

The first category highlights stark occupational and demographic disparities in suicidality. Firefighters report lifetime suicidal ideation rates of 46.8% [11–13], while EMS personnel face a tenfold higher suicide risk than civilians [14–16, 24]. Wildland firefighters and dispatchers also exhibit elevated risks, with 22% and 32% reporting suicide attempt histories or ideation, respectively [17, 18]. Demographic variations further underscore vulnerabilities, particularly among female firefighters [13, 19–21], Indigenous groups [15, 22], and retirees [23]. Trauma exposure is nearly universal, with 91.5% of firefighters [19], 94% of dispatchers [18], and 98% of EMS personnel [16] exposed to high trauma. PTSD prevalence ranges from 18.9% to 25.4% [17, 26], with symptoms strongly correlating with suicidality [13, 24, 25].

Psychological and occupational risk factors

The psychological burden borne by first responders manifests through a complex interplay of mental health comorbidities and occupational stressors that collectively exacerbate suicide risk. Depression and anxiety emerge as pervasive conditions, with mean PHQ-9 and GAD-7 scores of 8.35 and 6.88 respectively [24, 26] - levels that approach or exceed clinical thresholds. The severity of this burden is underscored by findings that depression alone increases the odds of suicidal ideation nearly ninefold (OR = 8.92) [20, 27], suggesting mood disorders represent one of the most potent risk factors in this population.

Substance use disorders compound this risk through multiple pathways. Hazardous drinking affects 38.8% of first responders [26, 28], while alcohol use disorders (AUDs) serve as both a maladaptive coping mechanism for trauma and a mediator in the PTSD-suicide pathway [25, 29]. Sleep disturbances, particularly insomnia, create an additional vicious cycle by worsening PTSD symptoms while simultaneously mediating their relationship with suicidal ideation [23, 25]. This triad of depression, substance misuse, and sleep disruption forms a particularly lethal combination that demands integrated treatment approaches.

Occupational culture and conditions further amplify these psychological risks. The deeply ingrained “culture of stoicism“ [12, 24, 30] discourages emotional expression and help-seeking, while workplace bullying directly predicts suicide plans and attempts [31]. Burnout manifests as emotional exhaustion that correlates strongly with suicide risk scores (β = 0.42) [15, 16, 32], particularly among EMS personnel with repeated suicide exposure. These occupational stressors interact synergistically with psychological vulnerabilities - for instance, the combination of high PTSD symptoms and low distress tolerance markedly increases suicide risk [19].

The cumulative impact of these factors creates a perfect storm of risk that varies by occupational subgroup. Firefighters face unique risks from interpersonal factors like perceived burdensomeness [28], while EMS personnel are particularly vulnerable to burnout from repeated trauma exposure [16]. This heterogeneity underscores the need for tailored interventions that address both universal psychological vulnerabilities and occupation-specific stressors. The findings collectively highlight that suicide prevention in first responders must move beyond symptom management to transform occupational cultures and address the root causes of psychological distress.

Systemic and cultural barriers

The structural obstacles preventing effective mental health care for first responders form a complex web of institutional, cultural, and geographical barriers that perpetuate the silent crisis of responder suicidality. At their core, stigma and systematic underreporting of psychological distress remain entrenched, fueled by legitimate fears of professional consequences including perceived weakness, missed promotions, or even job loss [13, 24, 30, 33, 34]. This stigma is particularly pronounced in male-dominated emergency service cultures that valorize stoicism and equate emotional vulnerability with professional incompetence [13, 14]. The resulting “code of silence” creates a paradox where those routinely exposed to trauma are discouraged from seeking help for trauma-related disorders.

Geographical disparities in access to care present another formidable barrier. Rural first responders face particularly acute shortages of mental health services, with Employee Assistance Programs (EAPs) either nonexistent or woefully inadequate to meet demand [26, 30]. Even in urban areas, utilization remains shockingly low - a mere 27% of dispatchers report comfort discussing mental health concerns [18], suggesting systemic failures in program design and implementation rather than simple service availability. These access issues are compounded by critical shortages of clinicians trained in both trauma-informed care and the unique occupational contexts of emergency services [15, 32]. Many mental health providers lack understanding of firehouse culture, shift work challenges, or the cumulative impact of repeated trauma exposure, leading to misdiagnosis or ineffective treatment.

The training pipeline for first responders reveals another systemic shortcoming. While technical skills receive extensive instruction, mental health training remains inconsistent and often superficial [24, 30]. Most programs fail to adequately address suicide prevention, trauma coping strategies, or help-seeking behaviors. This training deficit perpetuates harmful misconceptions and leaves personnel unprepared to support colleagues in crisis.

Despite these challenges, promising solutions are emerging. Grassroots initiatives led by peer advocates within responder communities have proven particularly effective in bridging the trust gap [30]. Houston’s mandatory officer training program, achieving 85% completion rates [34], demonstrates how institutional commitment can overcome cultural resistance. However, these successes remain localized and fragile, requiring broader policy support and funding to achieve system-wide impact.

The interplay of these barriers creates a perfect storm where even available services go underutilized. Structural reforms must simultaneously address stigma through cultural change initiatives, improve geographic access through telemedicine and mobile crisis units, and mandate comprehensive mental health training for both responders and clinicians. Without such multi-pronged interventions, systemic barriers will continue to undermine even the most clinically effective treatment modalities.

Interventions and solutions: a multidimensional approach to suicide prevention

The synthesis of evidence points to an urgent need for comprehensive, multilayered interventions that address the complex etiology of suicide risk among first responders. At the clinical level, trauma-focused psychotherapies demonstrate particular efficacy, with Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) showing significant reductions in both post-traumatic stress symptoms (PTSS) and suicidality [22, 29, 34]. These evidence-based approaches help responders process traumatic experiences and modify maladaptive cognitions, with effects that extend beyond symptom reduction to improve overall functioning and quality of life.

Peer-support programs emerge as a particularly promising intervention, leveraging the unique trust and understanding among colleagues to facilitate help-seeking [13, 16, 29]. These programs range from formal peer-counseling initiatives to informal “buddy systems,” all sharing the common benefit of reducing isolation while overcoming barriers posed by traditional mental health stigma. When properly implemented with adequate training and organizational support, peer networks can serve as early warning systems while fostering a culture of mutual support.

Early identification through routine mental health screenings represents another critical component of prevention [20, 22]. Regular, mandatory assessments using validated tools for PTSD, depression, and alcohol abuse [23] enable timely intervention before crises develop. Such screenings should be normalized as part of occupational health protocols, analogous to physical health examinations, with particular attention to high-risk periods following critical incidents or during career transitions.

Organizational-level strategies demonstrate that systemic change is both possible and impactful. Houston’s landmark 3-phase suicide prevention program, which achieved five consecutive years without active-duty suicides [34], provides a replicable model combining education, peer support, and leadership engagement. Similarly, means restriction policies [14]- including secure firearm storage protocols and medication monitoring - have shown particular effectiveness given the impulsive nature of many suicide attempts in this population.

Cultural transformation remains fundamental to sustainable change. Destigmatization campaigns that feature respected leaders sharing their mental health journeys [21, 22] can reshape organizational norms, while skills-based training in emotional literacy and help-seeking [13, 21] equips personnel with concrete alternatives to silence and suffering. These efforts must be reinforced through policy changes that guarantee confidentiality and protect career advancement opportunities for those seeking care.

The most effective interventions adopt an integrated approach that simultaneously addresses individual psychological needs while transforming organizational cultures. Future directions should explore technology-enhanced solutions (e.g., telehealth, mobile apps) to improve access, as well as the development of responder-specific treatment protocols that account for occupational stressors and trauma exposure patterns. Ultimately, saving those who save others requires nothing less than a fundamental reimagining of mental healthcare in emergency services - one that prioritizes prevention, honors lived experience, and makes psychological wellness as non-negotiable as physical safety.

Despite its comprehensive scope, this review has several limitations, including the predominance of cross-sectional studies, which limit causal inferences, and the overrepresentation of U.S.-based research, potentially restricting generalizability to non-Western contexts. Additionally, reliance on self-reported data may introduce bias, while the exclusion of non-English studies could overlook valuable insights from diverse populations. Future research should prioritize longitudinal designs to establish temporal relationships, expand geographic and cultural diversity to capture global variations, and incorporate mixed-methods approaches to deepen understanding of contextual factors. Investigations into the long-term efficacy of interventions, particularly in low-resource settings, are also needed to develop scalable, culturally adapted solutions.

Conclusion

In conclusion, the findings of this systematic review underscore the urgent need for a comprehensive and multi-faceted approach to mitigate the high prevalence of suicidal behaviors among first responders. The evidence reveals that this population faces unique and compounded risks due to occupational trauma, mental health comorbidities, and systemic barriers, all of which demand targeted interventions. Clinically, evidence-based therapies such as cognitive processing therapy and prolonged exposure have shown promise in reducing PTSD symptoms and suicidality, while peer-support programs offer a culturally sensitive avenue for trauma mitigation. Organizationally, implementing routine mental health screenings and restricting access to lethal means are critical steps toward early identification and prevention. Policy reforms must address the pervasive stigma and structural gaps that hinder access to care, particularly for underrepresented subgroups such as rural responders, women, and minorities. Furthermore, fostering cultural shifts that promote help-seeking behaviors and destigmatize mental health struggles is essential for long-term change. The review also highlights significant gaps in current research, emphasizing the need for longitudinal studies to establish causal relationships, as well as investigations that include diverse geographic and demographic populations to ensure the scalability and applicability of interventions. By integrating clinical, organizational, and policy strategies, stakeholders can develop actionable solutions that honor the sacrifices of first responders and safeguard their mental well-being. The time to act is now; the silent crisis on the frontlines can no longer be ignored.

Author contributions

Author contributions: All listed authors have made substantial contributions to the development and writing of this article.

Funding

This research received no specific grant from any funding agency.

Data availability

Initial data available on request from the authors.

Declarations

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Consent for publication

All authors consented to the publication of this article.

Competing interests

The authors declare no competing interests.