Posttraumatic stress disorder (PTSD) and co-occurring psychological issues among Turkish metropolitan firefighters Running head: Psychological issues in firefighters with PTSD

doi:10.21203/rs.3.rs-5013659/v1

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Posttraumatic stress disorder (PTSD) and co-occurring psychological issues among Turkish metropolitan firefighters Running head: Psychological issues in firefighters with PTSD

https://doi.org/10.21203/rs.3.rs-5013659/v1

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Objectives. This study aimed to investigate the co-occurrence of childhood trauma, dissociation, suicidality, and depression with posttraumatic-stress disorder (PTSD) among professional firefighters working in metropolitan fire departments in Turkey.

Methods. A cross-sectional study was conducted among 760 male firefighters aged 24-55 years with 2-35 years of work experience. Participants completed self-report questionnaires, including the PTSD Checklist for DSM-5 (PCL-5), Childhood Trauma Questionnaire-33 (CTQ-33), Dissociative Experiences Scale (DES), Suicidal Behaviors Questionnaire-4 (SBQ-4), and Patient Health Questionnaire-9 (PHQ-9).

Results. Using a PCL-5 score ≥33 as the cutoff for probable PTSD, 28.5% of the participants met the criteria. Firefighters with PTSD showed significantly higher rates of childhood trauma (51.2% vs. 28.4%, p < 0.001), dissociation (52% vs. 10% above the clinical cut-off, p < 0.001), suicidal ideation (54.8% vs. 37.8%, p < 0.001), and depression (100% vs. 34.4% with at least mild symptoms, p < 0.001) than those without PTSD. PTSD severity positively correlated with childhood trauma (r = 0.42, p < 0.001), dissociation (r = 0.58, p < 0.001), suicidal ideation (r = 0.39, p < 0.001), and depression (r = 0.61, p < 0.001). Childhood trauma emerged as a significant predictor of PTSD status (odds ratio [OR] = 2.63, 95% CI: 1.89-3.67, p < 0.001).

Conclusions. The findings highlight the significant co-occurrence of PTSD with childhood trauma, dissociation, suicidality, and depression among metropolitan firefighters. These results underscore the importance of comprehensive mental health screening and targeted interventions for firefighters, particularly in addressing the interplay between PTSD and other psychological issues.

post-traumatic stress disorder

childhood trauma

dissociation

suicidality

depression

firefighters

metropolitan fire department

Firefighters, as a professional group, are frequently exposed to traumatic events due to the nature of their work. These events can significantly impact their mental health and lead to various psychological issues (Jones, 2017; Carleton et al., 2018). Among these issues, Post-Traumatic Stress Disorder (PTSD) stands out as a major concern. PTSD is characterized by a range of psychological symptoms that occur after experiencing a traumatic event and can severely disrupt daily functioning (American Psychiatric Association, 2013).

Despite the significant mental health challenges faced by firefighters globally, research on their mental health in Turkey, particularly in metropolitan areas, is limited (Cankardas and Sofuoglu, 2022). Turkish firefighters face unique challenges compared to their counterparts in other countries. Rapid urbanization and population growth in Turkish metropolitan areas have led to increased fire risks in densely populated neighborhoods. Additionally, Turkey's location in a seismically active region means firefighters often respond to earthquakes and their aftermath. Cultural context, including strong family ties and societal expectations, may also influence how Turkish firefighters perceive and cope with traumatic experiences.

This study aimed to examine the unique challenges and mental health problems faced by Turkish firefighters, specifically investigating the prevalence and severity of childhood trauma, dissociation, suicidal ideation, and depression in addition to PTSD. The selection of these psychological issues in relation to PTSD was based on their potential to significantly affect firefighters' job performance and overall quality of life. Childhood trauma is a known risk factor for developing PTSD in adulthood (Roth et al., 2022). Dissociation can occur in response to traumatic experiences and may exacerbate PTSD symptoms (Boyd et al., 2018). Suicidal ideation is more prevalent among individuals with PTSD and poses a significant risk to firefighters (Healy and Vujanovic 2021). Depression, frequently co-occurring with PTSD, can complicate the treatment process (Wolffe et al. 2023).

This study hypothesizes that firefighters with PTSD will exhibit higher levels of childhood trauma, dissociation, suicidal ideation, and depression compared to those without PTSD. We anticipate a positive correlation between PTSD symptom severity and the intensity of these co-occurring psychological issues. Additionally, we propose that childhood trauma may be a significant risk factor for PTSD development in this population. These hypotheses are grounded in the existing literature on trauma in high-risk professions while considering the unique context of Turkish firefighters.

The results of this study aim to provide a better understanding of the mental health needs of firefighters in Turkey and contribute to the development of policies and intervention programs. By understanding the co-occurrence of PTSD and other psychological issues, mental health professionals may be better equipped to provide comprehensive and targeted interventions in this population.

Study design and participants

This cross-sectional study was conducted in 2023 among professional firefighters working in the Istanbul Metropolitan Fire Department in Turkey. Male firefighters aged 24–55 years with 2–35 years’ work experience participated in this study. The sample size was determined using a 20:1 subject-to-item ratio, a common rule of thumb in survey research.

Recruitment was conducted by the Istanbul Metropolitan Fire Department. All active-duty firefighters were invited to participate via departmental emails and internal communication channels. Participation was voluntary and anonymous. Data were collected using online survey tools to ensure anonymity and ease of access. Participants were given a four-week window to complete the questionnaires, with weekly reminder emails sent to encourage participation. Of the 830 firefighters who initially consented, 760 completed all the questionnaires and were included in the final analysis.

The study protocol was approved by the Ethics Committee of Istanbul University-Cerrahpasa (Approval No. 2023/22, dated January 3, 2023). All participants provided informed consent after being fully informed about the study's objectives and methodology.

Measures

1-PTSD Checklist for DSM-5 (PCL-5): A 20-item self-report measure assessing DSM-5 PTSD symptoms. The Turkish version validated by Boysan et al. (2017) was used, with a cut-off score of ≥ 33 indicating probable PTSD.

2-Childhood Trauma Questionnaire-33 (CTQ-33): A self-report measure assessing five types of childhood maltreatment. The Turkish version validated by Şar et al. (2021) was used, with the total scores ranging from 30 to 150.

3-Dissociative Experiences Scale (DES): A 28-item self-report measure of dissociative experiences. The Turkish version validated by Yargic et al. (1995) was used, with scores > 30 indicating possible dissociation.

4-Suicidal Behaviors Questionnaire-4 (SBQ-4): A 4-item measure assessing different dimensions of suicidality. The Turkish version, validated by Bayam et al. (1995), was used, with total scores ranging from 0 to 14.

5-Patient Health Questionnaire-9 (PHQ-9): A 9-item self-report measure assessing depression severity. The Turkish version validated by Sari et al. (2016) was used, with scores ranging from 0 to 27.

Statistical Analysis

Data were analyzed using GraphPad Prism version 9 (USA). Descriptive statistics were used to summarize the demographic information and questionnaire scores. The sample was divided into two groups based on the PCL-5 scores: probable PTSD (score ≥ 33) and non-PTSD (score < 33).

Chi-square tests were used for categorical variables, and Mann-Whitney U tests were used for continuous variables to compare the PTSD and non-PTSD groups. Spearman's rank correlation coefficient assessed relationships between PTSD severity and other psychological variables.Missing data were analyzed for randomness and percentages.

Participants with more than 10% missing data on any scale were excluded. For participants with < 10% missing data, multiple imputations were used p-value < 0.05 was considered statistically significant for all analyses.

The final sample comprised 760 firefighters. The median age was 40 years (range: 24–55 years), and the median work experience was 14 years (range: 2–35 years). Most participants (n = 603, 79.3%) were married and 381 (50.1%) had higher education.

Using the PCL-5 cutoff score of 33, 217 participants (28.5%) met the criteria for probable PTSD. The median PCL-5 scores for the PTSD and non-PTSD groups were 39 (IQR: 33–41) and 22 (IQR: 20–27), respectively (n = 543, 71.5%).

Comparison of PTSD and Non-PTSD Groups

Traumatic life events

Analysis of the LEC-5 data revealed that participants with PTSD reported a significantly higher number of distressful life events than those without PTSD (62.2% vs. 37.4% reporting 1–8 events; χ² = 15.73, p < 0.001).

Childhood trauma

The mean CTQ-33 score was significantly higher in the PTSD group (M = 51.2, SD = 15.3) compared to the non-PTSD group (M = 42.7, SD = 12.8; t(758) = 7.45, p < 0.001).

Dissociation: DES scores were significantly higher in the PTSD group (median: 31, IQR: 19–49) compared to the non-PTSD group (median: 10, IQR: 7–22; U = 32145, p < 0.001). In the PTSD group, 52% of the participants scored above the clinical cut-off for dissociation compared to 10% in the non-PTSD group (χ² = 142.67, p < 0.001).

Suicidal ideation: SBQ-4 scores were significantly higher in the PTSD group (median: 3, IQR: 0–3) compared to the non-PTSD group (median: 0, IQR: 0–2; U = 41236, p < 0.001). In the PTSD group, 54.8% of the participants reported positive suicidal ideation compared to 37.8% in the non-PTSD group (χ² = 18.92, p < 0.001).

Depression: PHQ-9 scores were significantly higher in the PTSD group (median: 15, IQR: 10–20) compared to the non-PTSD group (median: 5, IQR: 2–8; U = 28754, p < 0.001). All participants in the PTSD group (100%) reported at least mild depressive symptoms compared to 34.4% in the non-PTSD group (χ² = 276.31, p < 0.001).

Correlations between PTSD severity and other psychological variables

PTSD severity (PCL-5 score) was significantly and positively correlated with childhood trauma (r = 0.42, p < 0.001), dissociation (r = 0.58, p < 0.001), suicidal ideation (r = 0.39, p < 0.001), and depression (r = 0.61, p < 0.001).

Association between childhood trauma and PTSD

Logistic regression analysis was conducted with PTSD status as the dependent variable and the CTQ-33 total score as the primary independent variable. Age, years of service, and educational level were included as covariates. The CTQ-33 total score emerged as a significant predictor of PTSD status (OR = 2.63, 95% CI: 1.89–3.67, p < 0.001), even after controlling for demographic variables.

The results are presented visually in Figs. 1–5.

This study investigated the co-occurrence of childhood trauma, dissociation, suicidality, and depression with PTSD in professional firefighters in a metropolitan fire department in Turkey. Our findings revealed a complex interplay between PTSD and other psychological issues, highlighting the significant mental health challenges faced by firefighters.

Our study found a significant prevalence of PTSD (28.5%) among firefighters, which is consistent with international studies reporting PTSD rates ranging from 20–32% (Healy & Vujanovic, 2018; Kim et al., 2018). This prevalence underscores the substantial mental health burden faced by firefighters in Turkey and globally. However, it is important to note that PTSD rates vary depending on context and specific traumatic events. For instance, Skogstad et al. (2015) found a surprisingly low prevalence of possible PTSD (1.3%) among first responders who worked in proximity to the 2011 Norway terror attack. These contrasting results highlight the complex nature of the development of PTSD and the potential influence of cultural factors, working conditions, and support systems.

Childhood trauma emerged as a significant predictor of PTSD status in our study population. This aligns with previous research suggesting that adverse childhood experiences may increase vulnerability to PTSD in adulthood, particularly in high-stress occupations (Roth et al. 2022). Our findings emphasize the need for early intervention and support in firefighters with a history of childhood trauma. Recent research by Leonard et al. (2023) has also highlighted the role of insecure adult attachment styles in PTSD symptom severity among firefighters, suggesting that attachment styles may influence PTSD symptoms through the perceived ability to withstand emotional distress. These findings underscore the complex interplay between developmental factors and PTSD among firefighters.

The high prevalence of dissociative experiences among firefighters with PTSD (52% above the clinical cutoff) is particularly concerning. Dissociation may serve as a coping mechanism in response to traumatic experiences but can also exacerbate PTSD symptoms and impair occupational functioning (Boyd et al., 2018). This underscores the importance of addressing dissociative symptoms in firefighter PTSD treatment programmes.

Our study revealed elevated rates of suicidal ideation in the PTSD group (54.8%), highlighting the need for suicide prevention strategies in fire departments. This finding aligns with previous research indicating an increased suicide risk among firefighters with PTSD (Healy & Vujanovic, 2021). However, Lee (2019) found that perceived social support could act as a protective factor, potentially mitigating the impact of trauma on PTSD symptom development. These findings emphasize the importance of enhancing social support networks as a means of building resilience in high-risk populations. The universal presence of mild depressive symptoms in firefighters with PTSD is a striking finding, suggesting that integrated treatment approaches addressing both PTSD and depression may be necessary. Furthermore, recent research by Leonard et al. (2023) highlighted the complex relationship between PTSD symptoms and alcohol use among firefighters mediated by emotion regulation difficulties. These findings collectively emphasize the need for comprehensive and multifaceted mental health interventions for firefighters.

Zegel et al. (2023) introduced the concept of distress overtolerance in relation to PTSD symptoms among firefighters. Their findings suggested that the tendency of firefighters to persist through extremely high levels of distress may play a role in the development and maintenance of PTSD symptoms. This aligns with our observations on the complex interplay between PTSD and other psychological issues. A recent systematic review by Serrano-Ibáñez et al. (2022) identified several risk and protective factors of PTSD in firefighters, including operational stress, job duration, burnout, and dispositional mindfulness. These findings complement our results and underscore the need for a multifaceted approach to firefighters’ mental health.

Our study has several strengths, including its large sample size, use of validated measures, and focus on the understudied population of Turkish firefighters. However, limitations should be noted. The cross-sectional design precludes causal inferences, and the use of self-report measures may introduce response bias. Additionally, the sample was limited to male firefighters from a single metropolitan area, which may limit generalizability.

Future research should explore longitudinal relationships between these psychological variables and investigate protective factors that may enhance resilience among firefighters. Cross-cultural comparisons could help to elucidate the role of cultural factors in the expression and experience of PTSD and related psychological issues. Studies including female firefighters are also warranted as they may face unique challenges that affect their mental health (Jahnke et al., 2019).

These findings have important implications for practice and policy. Fire departments should implement comprehensive mental health programs that include regular screenings, early interventions, and access to evidence-based treatments for PTSD and related conditions. Developing culturally appropriate interventions for Turkish firefighters can enhance the effectiveness of mental health programs.

This study provides valuable insights into the mental health challenges faced by Turkish firefighters, highlighting the complex interplay between PTSD and other psychological issues. These findings can inform the development of more effective prevention, screening, and treatment strategies for firefighters, ultimately contributing to improved mental health outcomes and occupational functioning in this critical profession.

Ethical Approval and Consent to Participate

The study protocol was approved by the Social and Humanities Research Ethics Committee of the Istanbul University-Cerrahpasa, Istanbul, Turkey; Approval No: 2023/22 dated Jan 03, 2023) after the approval of Fire Department of Istanbul Metropolitan Municipality.

All participants provided written informed permission after being fully informed about the goal and methodology of this study. This study was performed in line with the principles of the Declaration of Helsinki.

Consent for publication

Not Applicable.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not available because of institutional reasons.

Conflict of Interests

The authors declare they have no financial (or non-financial) interests.

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

Author Contributions

All authors contributed to the concept and design of the study. Ahmet Erhan Bakirci was responsible for data collection. Vedat Sar was involved in material preparation and data collection. Ali Çetin was responsible for statistical analyses and writing the draft manuscript. Before submitting the final manuscript for publication, all authors contributed to its writing and read and approved it.

Acknowledgements

We extend our heartfelt gratitude to all the firefighters who actively took part in the study, dedicating their valuable time and selfless devotion. We would like to express our appreciation to the Administration of Istanbul Municipality Metropolitan Fire Service for their essential contribution, assistance, and dissemination of the survey to participants.

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No competing interests reported.

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You are reading this latest preprint version

Posttraumatic stress disorder (PTSD) and co-occurring psychological issues among Turkish metropolitan firefighters Running head: Psychological issues in firefighters with PTSD

Status:

Version 1

Abstract

Figures

Introduction

Methods

Study design and participants

Measures

Statistical Analysis

Results

Comparison of PTSD and Non-PTSD Groups

Correlations between PTSD severity and other psychological variables

Association between childhood trauma and PTSD

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1