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]