Introduction

Police officers, firefighters, and emergency medical service personnel are often the first to respond to a crisis or emergency. As such, these first responders may experience significant stress and/or be exposed to traumatic events in carrying out their jobs. Compounded over time, exposure to stressful events may contribute to diminished mental health and wellness. Similarly, a single, extremely stressful or traumatic event can negatively affect mental health for those involved or who witness the event.

Congress, the Administration, and executive agencies have recognized the mental health-related risks of first responders and have initiated efforts to prevent or remediate these issues. Federal efforts to improve first responder mental health involve multiple programs spread out across several executive departments and agencies. The federal government has generally taken a piecemeal approach to first responder mental health initiatives. Most programs are the efforts of a sole executive department with jurisdiction over the type of first responder (e.g., Department of Justice and law enforcement officers) with few interagency initiatives and little overall coordination.

Congress may be interested in building on current efforts, addressing current gaps, or trying to improve existing programs related to first responder mental health. For example, rather than use a broad array of individual independent programs across multiple agencies, Congress might consider promoting a more streamlined approach with a greater emphasis on interagency coordination and consultation. This approach could include more comprehensive mental health prevention and treatment services that address any gaps in care. First responders may benefit from a spectrum of mental health services devoted both to the chronic stressors of their work environments and to acute mental health crises or traumatic events. Congress could require the federal first responder mental health response to include greater attention to the course of mental health, from prevention to treatment and recovery for mental disorders, for example. Similarly, in reauthorizing or appropriating funding for federal grants for first responders, Congress may consider ways to provide sustainable financing systems for new or existing programs, particularly since several current programs involve discretionary grants provided once to grantees. Additionally, many existing programs for mental health or first responders do not explicitly address both of these issues; grants for mental health could be used for first responders (but not necessarily) and first responder programs may not require mental health-related activities. Few existing funding streams are solely dedicated to first responder mental health.

When supporting mental health interventions for first responders, Congress might consider the empirical support for such programs and promote the use of evidence-based practices. Not all post-crisis or trauma-based interventions have been found to be safe and effective. Research remains mixed on the effectiveness of certain treatments, with some studies suggesting that some interventions—such as particular crisis response programs—may actually promote harm.

Federal efforts to promote mental health services for first responders might also address barriers to utilization, such as the availability of treatment services tailored to these occupations, or issues surrounding stigma. Congress may also consider promoting a systemic approach to mental health services, with training not only for first responders themselves, but also for management.

This report provides information on federal programs targeting the mental health of first responders. The programs included in this report all intend to improve mental health outcomes, albeit in different ways. Some federal programs address first responder mental health generally, while others may target a specific population (e.g., law enforcement officers) or goal (e.g., suicide prevention). Some programs are explicitly for mental health or suicide-related activities, while others could be used for these purposes, but are not necessarily intended for them exclusively.

The programs noted here focus specifically on mental health, though some may support other behavioral health issues such as substance use. While some research suggests first responders may have higher rates of unhealthy substance use behaviors, these may be secondary to mental health issues.¹ Law enforcement officers, firefighters, and emergency medical personnel may develop unhealthy substance use behaviors as coping strategies for job-related stress or other mental health problems.² This report focuses on first responder mental health, though it includes programs that address behavioral health generally if mental health-related activities are a primary enterprise. A full discussion of substance use in this population—particularly substance misuse and substance use disorders—is beyond the scope of this report.

In this report, federal activities are displayed by the type of first responder (i.e., law enforcement officers, firefighters, and emergency medical personnel) and the primary corresponding executive department of jurisdiction. An additional section describes related federal programs seeking to address mental health and suicide administered by the Department of Health and Human Services (HHS). The final section describes issues Congress may consider related to the mental health of first responders.³

Mental Health of First Responders

Research has shown that the types of stressful work conditions first responders often experience can contribute to the development of new mental health conditions or exacerbate pre-existing mental health conditions.⁴ Comprehensive national data on first responder mental health do not exist. However, some research suggests that first responders may have higher risks for mental health conditions, including suicidal thoughts and behaviors.⁵ Results from one study, for example, found that firefighter and emergency medical services (EMS) personnel—such as emergency medical technicians (EMTs) and paramedics—experience higher rates of lifetime suicidal ideation and attempts than the general population.⁶ Another study found relatively high rates of suicidal thoughts and behaviors among firefighters.⁷ EMTs may also have higher rates of suicide than non-EMTs.⁸ Similar results have been found in studies on law enforcement, describing a higher risk for suicide amongst police officers compared to the general population.⁹ One white paper found that police and firefighters may be more likely to die by suicide than in the line of duty.¹⁰ The research regarding mental health risks for first responders appears mixed however, with some studies suggesting that suicide rates among some first responders may actually be lower than the general population.¹¹ A systematic review of 63 studies examining suicide in police officers, firefighters, EMTs, and paramedics revealed elevated risk for suicide among first responders, but also noted a dearth of rigorous longitudinal research which could provide more conclusive information.¹²

Although few studies have carefully examined the exact mechanisms behind the relationship between experiences in the workplace and mental health for first responders, some believe frequent situational stressors and/or exposure to traumatic incidents for individuals in these occupations can result in higher rates of mental health concerns and suicide. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), trauma is defined as exposure to actual or threatened death, serious injury, or sexual violence. An individual may experience such an event first hand, witness it, or learn that the event occurred to a friend or colleague. Exposure to trauma can lead to a number of mental health issues, including increased symptoms of anxiety and depression. In some instances, exposure to trauma can result in post-traumatic stress symptoms, including post-traumatic stress disorder (PTSD). One study found that, for firefighters, cumulative exposure to other people's suicide attempts may be a risk factor for individual suicidal thoughts and behaviors.¹³

There appears to be little research regarding first responders seeking or utilizing mental health treatment.¹⁴ A few studies suggest that first responders may experience barriers to accessing and utilizing mental health treatment. One review of the literature found that first responders often described not knowing where to get help, or having difficulties scheduling an appointment with a provider.¹⁵ Other barriers included concerns about the confidentiality of services and fears that seeking psychological services would have a negative effect on one's career.¹⁶ Barriers to accessing care may be particularly problematic for certain subgroups of first responders, such as volunteer firefighters and police officers in small departments.¹⁷

First responders may also experience barriers to care unique to their fields, such as stigma surrounding mental health treatment and a culture of not seeking help. One study found that on average, about one in three first responders experiences stigma regarding mental health.¹⁸ In another study, first responders described not feeling like they can "show weakness" or having fears of being perceived that they are not "up to the job."¹⁹ This study also found that lack of knowledge about mental health and mental health treatment was a significant barrier to help-seeking for first responders.

Federal Programs Addressing First Responder Mental Health

Recognizing the unique risks for police, firefighters and emergency medical personnel, the federal government has made efforts to address first responder mental health. Multiple executive departments, including the Department of Justice (DOJ), the Department of Homeland Security (DHS), and HHS, operate mental health programming for first responders. Some programs focus on mental health for occupations generally, while others target specific occupations (such as law enforcement officers) or focus on specific circumstances such as disaster response personnel. In instances where first responders are employees of the federal government, the federal agencies responsible may provide in-house resources for these individuals.²⁰

Federal efforts to address the mental health of first responders are described below. Each section describes the activities of the executive department with primary responsibility for the occupation and provides additional related resources.²¹

Law Enforcement

DOJ has several initiatives and grant programs that provide assistance to state and local governments for issues related to law enforcement officers' mental health. Programs under the Law Enforcement Mental Health and Wellness Act (LEMHWA, P.L. 115-113) specifically focus on the mental health of law enforcement officers. Other programs operated by DOJ, such as the Edward Byrne Memorial Justice Assistance Grant (JAG) program, the VALOR Officer Safety and Wellness Program, and the National Officer Safety Initiative can provide assistance for law enforcement officer mental health, but do not focus solely on this issue.

The Law Enforcement Mental Health and Wellness Act (LEMHWA) Program

LEMHWA, among other things, amended the authorizing legislation for the COPS program so that grants could be awarded to "establish peer mentoring mental health and wellness pilot programs within State, tribal, and local law enforcement agencies." Congress appropriated $2 million for FY2019 and $5 million for FY2020 under the COPS account in the Commerce, Justice, Science, and Related Agencies appropriations acts for "training, peer mentoring, and mental health program activities" as authorized by LEMHWA.²²

The COPS Office awards this funding under its LEMHWA Program. According to the COPS Office, funds are to be used to "improve the delivery of and access to mental health and wellness services for law enforcement through training and technical assistance, demonstration projects, and implementation of promising practices related to peer mentoring mental health and wellness programs."²³ The program funds projects that "develop knowledge, increase awareness of effective mental health and wellness strategies, increase the skills and abilities of law enforcement, and increase the number of law enforcement agencies and relevant stakeholders using peer mentoring programs."²⁴

Edward Byrne Memorial Justice Assistance Grant (JAG) Program

JAG is a formula grant program whereby funding is allocated to each state, the District of Columbia, and each of the territories to support a variety of criminal justice initiatives.²⁵ Each state's allocation is divided between the state and units of local government in the state based upon a statutorily defined formula.²⁶ Grant recipients can use their JAG funds for state and local initiatives for one or more of JAG's program purpose areas, which includes "mental health and related law enforcement and corrections programs, including behavioral programs and crisis intervention teams."²⁷

DOJ's Bureau for Justice Assistance (BJA) administers JAG and identifies "officer safety and wellness" as an area of emphasis for the program.²⁸ BJA encourages grant recipients to use some of their JAG funds to support health and wellness programs for law enforcement officers and to cover the cost of officers attending officer safety and wellness conferences that "enhance law enforcement education and awareness with the goal of preventing officer injury and/or death."²⁹

VALOR Initiative

BJA also administers the funding for the VALOR Officer Safety and Wellness Program. The initiative provides training, technical assistance, and specialized programs to law enforcement officers to "prevent violence against law enforcement officers and ensure officer safety, resilience, wellness, and survivability following violent encounters during the course of their duties."³⁰ The initiative consists of eight programs, one of which is a law enforcement suicide prevention training program which provides training and technical assistance that focuses on education, awareness, recognition, and prevention of law enforcement suicide. Congress provided $12 million for the VALOR Initiative for FY2020.

National Officer Safety Initiative

BJA created the National Officer Safety Initiative to support President Trump's executive order on preventing violence against federal, state, tribal, and local law enforcement officers.³¹ This initiative addresses law enforcement officer safety in three areas: law enforcement suicide, traffic safety, and a national public awareness and education campaign. In FY2018, BJA awarded a grant to the International Association of Chiefs of Police (IACP) to convene a national consortium of experts and stakeholder organizations and associations in the field of officer safety and wellness. The goals of the consortium were to produce a comprehensive report with recommendations on consistent definitions and terminology relating to officer suicide; policy and procedure updates; research and data collection improvements; effective messaging strategies; and promising practices in prevention, intervention, and post-intervention follow-up.³²

Additional Resources

Law Enforcement Mental Health and Wellness Act Reports

LEMHWA required DOJ to submit a report to Congress on mental health practices and services at the Departments of Defense and Veterans Affairs that could be adopted by federal, state, local, or tribal law enforcement agencies. The act also required DOJ to provide recommendations regarding the effectiveness of crisis lines for law enforcement officers, efficacy of annual mental health checks for law enforcement officers, expansion of peer mentoring programs, and assurance of privacy considerations for these types of programs. The COPS Office published a report in response to this mandate in March 2019.

• Community Oriented Policing Services, Law Enforcement Mental Health and Wellness Act: Report to Congress, available online at https://cops.usdoj.gov/RIC/Publications/cops-p370-pub.pdf.

The act also required the COPS Office to publish case studies of programs designed primarily to address officer mental health and well-being. In response to this mandate, the COPS Office published eleven case studies of mental health and wellness programs in ten law enforcement agencies and one call-in crisis line. Each case study discusses the program and its origin, focusing on elements that can be implemented elsewhere.

• Law Enforcement Mental Health and Wellness Programs: Eleven Case Studies, available online at https://cops.usdoj.gov/RIC/Publications/cops-p371-pub.pdf.

International Association of Chiefs of Police

The International Association of Chiefs of Police (IACP), a nonprofit organization, has a webpage that provides several resources related to law enforcement officer suicide prevention and awareness. Resources include a report that discusses suicide prevention and awareness with recommendations for command staff, common factors associated with suicide, and information on national and local suicide prevention resources; a report that discusses strategies for law enforcement agencies that want to include officer mental wellness as a core element of an officer safety and well-being program or reduce the threat of officer death by suicide; and information on sample suicide prevention programs that target law enforcement officers.

• IACP, Law Enforcement Suicide Prevention and Awareness: https://www.theiacp.org/resources/document/law-enforcement-suicide-prevention-and-awareness.

Police Executive Research Forum (PERF)

The Police Executive Research Forum (PERF), a nonprofit police research and policy organization, published a report in October 2019 discussing what the data can tell us about law enforcement officers who die by suicide, risk factors for suicide in the law enforcement profession, and warning signs that an officer might be contemplating suicide. The report also outlines 10 recommendations for steps that law enforcement agencies can take to help prevent officer suicide, including routine mental health checks, confidential support programs and training, and family support.

• An Occupational Risk: What Every Police Agency Should Do to Prevent Suicide among Its Officers, available online at https://www.policeforum.org/assets/PreventOfficerSuicide.pdf.

Blue H.E.L.P.

Blue H.E.L.P.,³³ a nonprofit organization that promotes awareness of mental health issues in the law enforcement community, collects and reports data on law enforcement officer suicides. These data have limitations, namely that they are voluntarily submitted to Blue H.E.L.P. by people who knew the officer who died by suicide and discovered through media searches by Blue H.E.L.P. staff, and may not be a comprehensive count of all law enforcement officer suicides. Despite these limitations, the data published by the organization are frequently cited by the media when discussing suicide by law enforcement officers.

Firefighters

Several federal initiatives seek to address mental health-related issues among firefighters. Often these efforts focus on suicide prevention, though they may also provide mental health services after critical incidents, or training on general mental health and well-being.

The National Park Service, U.S. Forest Service, and other federal agencies that employ firefighters directly, have taken steps to address suicide among their workforce and promote mental wellness. For example, the National Park Service (NPS) established a task force to address firefighter suicide among their employees. The task force developed a mental health self-assessment and tools for managers to talk to NPS firefighters about mental wellness and suicide. The NPS made these resources and tools available to the broader fire community.³⁴

Suicide Prevention and Mental Health Services

Some federal agencies provide suicide prevention information for fire departments at all levels of government (e.g., federal wildland firefighters, local firefighters, volunteer firefighters). For example, the U.S. Fire Administration (USFA), which is part of the Federal Emergency Management Agency (FEMA) within DHS, provides resources for all fire departments and encourages fire departments to work in partnership with mental health organizations.³⁵ The National Emergency Training Center (NETC) within FEMA provides research, resources, and best practices for fire departments, including mental health training models and best practices.³⁶ Additionally, the National Interagency Fire Center (NIFC) offers Critical Incident Stress Management (CISM) services to fire departments, which includes suicide prevention, intervention, and post-intervention services.³⁷

Federal agencies also provide funding for research and assistance with firefighter suicide prevention. For example, the National Institute for Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention within HHS and DHS/FEMA through its Fire Prevention and Safety Grant (FP&S) program, provided the National Fallen Firefighters Foundation funding to hold the Second Fire Service Suicide and Depression Summit in 2013.³⁸ In 2014, the Firefighter Behavioral Health Alliance—an independent nonprofit organization—received $23,750 in FP&S funds to support this organization's efforts to provide suicide awareness and prevention workshops.

Additional Resources

In addition to federal efforts, several nongovernmental organizations offer resources on suicide awareness and prevention for fire departments:

• Firefighter Behavioral Health Alliance (FBHA), a nonprofit organization, provides training to and runs workshops for fire departments and EMS organizations focusing on behavioral health awareness and suicide prevention: http://www.ffbha.org/resources/5-bugles-4-change/.
• The National Fallen Firefighters Foundation (NFFF) "Everyone Goes Home" initiative focuses on firefighter safety and health and wellness—including suicide prevention. The organization has produced a Fire Service Behavioral Health Management Guide: everyonegoeshome.com/wp-content/uploads/sites/2/2017/12/behavioral-health-mgmt-guide-122017.pdf., and a Guide for Fire Chiefs: http://www.firstrespondercenter.org/wp-content/uploads/2019/03/SuicideGuide_Chiefs.pdf.
• The First Responder Center for Excellence, an affiliate of NFFF, offers resources, research, and tools for individuals, leadership, clinicians on first responder behavioral health: firstrespondercenter.org/behavioral-health.
• The International Association of Fire Fighters has a Center of Excellence, which includes a mental health hotline (1-877-766-2901); resources for fire departments: https://www.iaffrecoverycenter.com/hotline/ptsd-mental-health/; and clinicians who can help firefighters overcome suicidal thoughts, manage behavioral health problems or begin recovery from addiction: https://www.iaffrecoverycenter.com/behavioral-health/.
• The International Association of Fire Chiefs offers resources for fire department leadership: https://www.iafc.org/search-results/#/suicide/page=1 and training for firefighters: iafc.org/events/event/2020/12/31/self-paced/surviving-the-job-emotional-self-care-for first-responders.
• The National Fire Protection Association's Fire Protection Research Foundation is supporting a research project, "Preventing Suicide Among Firefighters Through Implementation of Safety Planning Training for Peer Support Specialists" with funding from the DHS/FEMA Assistance to Firefighters Grant (AFG) Program and the Fire Protection Research Foundation: https://www.nfpa.org/-/media/Files/News-and-Research/Resources/Research-Foundation/Current-projects/ProjectSummaryFFSuicideIntervention.ashx.
• National Fire Service Behavioral Health Symposium 2020, see https://www.firstrespondercenter.org/event/national-fire-service-behavioral-health-symposium/.

Emergency Medical Services Personnel

Emergency Medical Services (EMS) provide acute medical care at the site of an emergency. EMS are part of a larger system of coordinated medical response, whereby multiple agencies and individuals work together to receive and respond to emergency calls. The organizational structure of EMS, including who provides and finances the services, varies significantly from community to community. EMS services can be based in a fire department, a hospital, an independent government agency (i.e., public health agency), a nonprofit corporation (e.g., Volunteer Rescue Squad), or be provided for by for-profit entities.³⁹

At the federal level, the Office of EMS in the Department of Transportation's National Highway Traffic Safety Administration (NHTSA) serves as a clearinghouse of information for EMS agencies. The Office of EMS provides support to the Federal Interagency Committee on EMS (FICEMS), a coordinating body focused on defining federal research priorities and initiatives to support the EMS community.⁴⁰ The member agencies include the Department of Defense (DOD), DHS, Department of Transportation (DOT), Federal Communications Commission (FCC), and HHS. This membership also receives input from community representatives who comprise the National EMS Advisory Council (NEMSAC).⁴¹ The FICEMS, along with the NEMSAC has focused on strengthening mental health and wellness and preventing suicides within the EMS community.⁴²

The federal government also provides funding to EMS agencies for some mental health and wellness activities. For example, EMS agencies that are not affiliated with a hospital, can apply for federal funding under FEMA's Assistance to Firefighter Grants for a variety of activities, including wellness and fitness activities. Wellness and fitness activities include programs aimed at strengthening the mental health of fire and EMS workers.⁴³ EMS agencies may also benefit from programs sponsored by affiliated fire departments, which may receive funding through FEMA's AFG programs. Additionally, recipients of FP&S grants are encouraged to partner with fire departments, including volunteer fire departments and EMS services, on grant-funded initiatives, including mental health initiatives. This may provide opportunities for EMS agencies to engage with professionals on the issue.

Additional Resources

For EMS agencies that are not part of a fire department, the federal government provides general resources for first responders. For example, the U.S. Fire Administration within FEMA provides links to the National Volunteer Fire Council's Fire/EMS helpline, which provides suicide prevention, mental health, and addiction services for firefighters.⁴⁴ The U.S. government may offer help to first responders during or after disasters, including mental health services. For example, during the Coronavirus Disease 2019 (COVID-19) pandemic, the Administration and executive agencies established the Federal Healthcare Resilience Task Force to lead the development of a comprehensive strategy for the U.S. healthcare system to manage its response to COVID-19, including support for healthcare workers.⁴⁵ The Task Force established an EMS/Pre-Hospital Team comprised of EMS and 911 experts from the CDC, FEMA, NHTSA Office of EMS, U.S. Army, U.S. Coast Guard, USFA, and nonfederal partners to provide state, local, tribal, and territorial first responders with resources to deal with the stress related to the pandemic.⁴⁶

Department of Health and Human Services (HHS) Resources

The U.S. Department of Health and Human Services supports the provision of mental health prevention and treatment services, the collection of public health data, and public health campaigns promoting mental health—including for some specific occupations or industries. This comes in the form of mandatory funding for mental health services through programs like Medicare and Medicaid, discretionary grant funding to states and other organizations for prevention or treatment activities, or technical assistance and other resources for grantees and industry organizations. HHS agencies, such as the Health Resources and Services Administration (HRSA), provide training and support for many medical providers in particular.

Historically, states—as opposed to the federal government—have borne the primary responsibility for the provision of community mental health services. This legacy continues today, with the bulk of federal discretionary funding for mental health services distributed to states via block grants. For example, the Substance Abuse and Mental Health Services Administration (SAMHSA) administers the Community Mental Health Services Block Grant to states and territories annually. The grants support activities related to prevention and treatment of mental health disorders. States have considerable flexibility with how they use these funds. Other HHS agencies, such as the Centers for Disease Control and Prevention (CDC), assist with the data collection and technical support surrounding mental illness and treatment-related activities. CDC's National Institute for Occupational Safety and Health specifically focuses on the safety and health of workers and they often offer programming specifically for first responders. Many mental health-related activities for first responders, therefore, may be state and local initiatives with possible support from certain federal programs.

Substance Abuse and Mental Health Services Administration (SAMHSA)

The Substance Abuse and Mental Health Services Administration is the federal agency primarily responsible for supporting community-based mental health and substance abuse treatment and prevention services. Located within HHS, SAMHSA provides federal funding to states, local communities, and private entities for mental-health related activities through block grants and other formula and discretionary grants. Through such grants, SAMHSA supports activities that include education and training, prevention programs, early intervention activities, treatment services, and technical assistance—often for specific populations (such as disaster response personnel) or areas of concern (such as suicide prevention). SAMHSA does not provide mental health treatment.

SAMHSA Suicide Prevention Resources

SAMHSA supports a number of programs addressing suicide prevention. Some of these initiatives target specific populations, such as young adults or Tribal communities, while others provide resources for the general population. SAMHSA's Suicide Prevention Resource Center, for instance, provides technical assistance, training, and resources to organizations working to develop suicide prevention strategies. On some occasions, SAMHSA and the Suicide Prevention Resource Center will publish materials targeting specific occupations, such as first responders.

SAMHSA mental health and suicide prevention for first responders resources:

• SAMHSA Suicide Prevention Resource Center: http://www.sprc.org/
• Resources for First Responders: http://www.sprc.org/settings/first-responders
• Resources for Law Enforcement: http://www.sprc.org/settings/law-enforcement

SAMHSA Disaster Technical Assistance Center (DTAC)

SAMHSA operates a Disaster Technical Assistance Center (DTAC) as the foundation of its disaster response initiatives.⁴⁷ Through the DTAC, SAMHSA partners with the Federal Emergency Management Agency (FEMA) to assists states, territories, tribes, and local entities with all-hazards disaster behavioral health response planning. SAMHSA DTAC uses appropriated funds for programs that support survivors of disasters as well as organizations and providers administering aid. For example, through an interagency agreement with FEMA, SAMHSA operates the Crisis Counseling Assistance and Training Program (CCP), which provides behavioral health outreach and psycho-educational services to individuals in areas affected by disasters, including response personnel.⁴⁸ Other SAMHSA DTAC initiatives include immediate crisis counseling via the Disaster Distress Helpline⁴⁹ and resource publication through the Disaster Behavioral Health Information Series resource collections.⁵⁰

SAMHSA DTAC resources:

• SAMHSA Disaster Technical Assistance Center resource portal: https://www.samhsa.gov/dtac/disaster-responders
• DTAC Tips for Disaster Responders: Preventing and Managing Stress: http://store.samhsa.gov/product/Preventing-and-Managing-Stress/SMA14-4873
• DTAC Tips for Disaster Responders: Identifying Substance Misuse in the Responder Community: http://store.samhsa.gov/product/Identifying-Substance-Misuse-in-the-Responder-Community/SMA14-4874
• DTAC online trainings for first responders: https://www.samhsa.gov/dtac/education-training
• DTAC online behavioral health trainings: https://www.samhsa.gov/dbhis-collections/online-trainings

Centers for Disease Control and Prevention (CDC)

The Centers for Disease Control and Prevention is the federal government's lead public health agency. CDC's mission is to "to protect America from health, safety and security threats, both foreign and in the [United States]."⁵¹ CDC is organized into a number of centers, institutes, and offices. Some of these focus on specific public health challenges (e.g., injury prevention); others focus on general public health capabilities (e.g., surveillance and data collection).⁵² CDC also operates the National Institute for Occupational Safety and Health which disseminates information related to occupational health for a variety of fields, including sometimes first responders.⁵³ CDC frequently makes data available and publishes reports on health and mortality outcomes, and provides resources on prevention and evidence-based interventions.

CDC suicide prevention resources:

• CDC report "Suicide Rates by Industry and Occupation – National Violent Death Reporting System, 32 States, 2016" (2020) ⁵⁴: https://www.cdc.gov/mmwr/volumes/69/wr/mm6903a1.htm
• CDC technical assistance package "Preventing Suicide: A Technical Package of Policy, Programs, and Practices": https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf

National Institutes for Health (NIH)

The National Institutes of Health (NIH) is the primary agency of the federal government charged with performing and supporting biomedical and behavioral research. The agency consists of the Office of the Director and 27 institutes and centers, each of which focuses on particular diseases or research areas in human health. Multiple institutes within NIH support various aspects of behavioral health research generally, but the National Institute for Mental Health (NIMH) represents the primary organization within NIH focusing on mental health. In addition to conducting and supporting research, NIMH provides authoritative information on mental disorders and resources for the public.

NIMH resources:

• NIMH mental health information: https://www.nimh.nih.gov/health/index.shtml
• NIMH research: https://www.nimh.nih.gov/research/index.shtml
• NIMH outreach and news: https://www.nimh.nih.gov/outreach/index.shtml

Issues for Congress

Congress, the Administration, and executive agencies have recognized the mental health-related risks of first responders and have initiated the aforementioned efforts to prevent or remediate these issues. Congress may be interested in building on these efforts, addressing current gaps, or trying to improve existing programs.

Tailoring Mental Health Programming to First Responders and Increasing Access

Some research suggests that first responders may experience barriers to accessing mental health treatment.⁵⁵ First responders may have the same access to mental health resources in their communities as others; however, specialized mental health prevention and treatment services geared toward the unique aspects of being a first responder may increase participation and reduce barriers to receiving care. For instance, in a survey conducted by the National Volunteer Fire Council (NVFC), more than 75% of firefighters indicated greater willingness to use a program that was tailored to their needs compared to a program for the general public, such as the national suicide hotline.⁵⁶

Supporting organizations that tailor programs for first responders, such as the Firefighter Behavioral Health Alliance, may increase services to first responders and reduce barriers to access. A challenge to this approach involves sustainable funding. For example, while FBHA received federal funding from the FP&S grant program, the funding is competitive and limited, and typically not awarded to the same organization year-over-year. Organizations receiving funding to establish mental health programs may then have to finance these programs from their own budgets, or close the program due to lack of sustained funding. Further, in some federal first responder grants, only fire or police departments can apply; nonprofit organizations—such as those focusing on first responder well-being—are not eligible to apply. In other first responder grant programs, spending on mental health (e.g., training, services) is not an eligible expense. In addition, workers who support first responders—such as 9-1-1 call takers and dispatchers—may also experience stress on the job. These stressors are expected to increase as communication systems improve, allowing callers to send images and videos from the scene to call-takers. These workers may also benefit from mental health programs and services.⁵⁷ In reauthorizing or appropriating funding for federal grants for first responders, Congress may consider expanding categories of eligible applicants or activities to support mental health services or establishing more sustained financing systems for these programs.

For example, the National Suicide Prevention Lifeline (1-800- 273-TALK) provides critical counseling and referral services for individuals contemplating suicide. While not specific to first responders, public safety agencies and organizations promote the Lifeline as a resource for individuals in these fields. In July 2020, the Federal Communications Commission designated 9-8-8 as the National Suicide Prevention Lifeline.⁵⁸ The shorter number is intended to make it easier to remember, however it is not yet operational (it is expected to be operational by July 16, 2022). When military veterans call the existing number, they are routed to services that are specific to individuals who have served in the military. Congress may consider following a similar template for first responders by enabling referrals to mental health services specific to this population. A coordinated list of programs and organizations specifically tailored to first responders may lead to increased access and use.

Addressing Barriers to First Responder Utilization of Mental Health Care

Improving access to treatment—even to tailored programs—may not alone significantly increase utilization of mental health treatment. Federal efforts to promote mental health services for first responders might also address other barriers to utilization, such as stigma. Research has identified stigma of mental health treatment as a barrier to receiving care for first responders specifically. One review of the research found that over a third of first responders identified stigma as a barrier.⁵⁹ Fears that treatment will not be confidential, could harm their careers, or could result in judgment from peers and superiors influence first responders' decision not to seek mental health treatment.⁶⁰ Law enforcement officers, firefighters, and emergency medical personnel may fear being viewed as "weak" or "not up to the job" by coworkers and leadership.⁶¹ In some instances, individuals may purposefully ignore symptoms and eschew care to avoid these perceived consequences. Congress may consider encouraging, prioritizing, or allowing mental health training not only for first responders, but also for management, through new or existing federal grant programs.

Some studies on first responder mental health care have identified facilitators to treatment utilization that could counteract barriers. When the effects of stress on mental wellness is acknowledged and individual first responders realize they are "not alone" in having difficulties coping or experiencing symptoms of a mental health issue, for instance, they are more likely to seek treatment.⁶² Responders included in one study noted that when their coworkers recognized that they needed help and when they had positive experiences with a mental health provider, they were more likely to use treatment services. Support from leadership and unions was also cited as an essential component to combatting stigma and promoting a culture of help-seeking.

Including a Spectrum of Mental Health Services

The federal government generally takes a piecemeal approach to first responder mental health initiatives. A more coordinated approach could include more comprehensive mental health prevention and treatment services that address any gaps in care. This might include attention to the course of mental health, from prevention to treatment and recovery. The federal compilation of services could include overall mental and behavioral well-being resources, prevention programs, diagnostic services, mental health treatment, crisis support interventions, or other behavioral health services such as those addressing substance use disorders. They may also seek to balance attention to mental health disorders as much as general mental wellness, resilience, and coping.

Recommendations from one study emphasized mental health screenings, education campaigns, and interventions after a trauma or critical incident as possible effective programs.⁶³ Other suggestions have focused on prescreening for preexisting mental health issues, improving coping strategies, boosting resilience, and enhancing social support.⁶⁴ For example, prescreening for mental health concerns—a strategy used in other high-stress fields such as the military—can help identify those individuals who are most at risk for negative psychological effects of trauma. Prescreening is designed to identify first responders who may benefit from additional supports, not as a tool to exclude individuals for the job. Congress may consider expanding or prioritizing eligible costs in federal grants to include mental health initiatives that can incorporate these activities.

Congress may also consider the types of mental health interventions for first responders when supporting or establishing these types of programs. Mental health programs can target a number of different aspects of psychological functioning. Some interventions are solely for the aftermath of a critical incident. These programs target trauma-related symptoms but may not be effective in addressing other aspects of mental well-being. Other programs are preventive. These interventions aim to build resiliency to lessen the risk of mental health issues after exposure to chronic stress or a traumatic incident. Suicide-related interventions may help with reducing mortality during a mental health crisis, but other complementary treatments may be necessary to address underlying mental health problems contributing to that crisis.

First responders may benefit from a spectrum of mental health services devoted to both the chronic stressors of their work environments and also acute mental health crises or traumatic events. Understanding the role of preexisting risk factors of first responders may also help identify individuals at high risk for mental health problems. An existing mental health concern, for example, could trigger an acute crisis. Prescreening may identify individuals entering these fields who are particularly at risk. Congress may choose to support a broad array of first responder mental health programs providing a spectrum of services or targeting certain subpopulations (such as police officers) or incident types (such as traumatic events). Alternatively, Congress could address several specific issues through a compilation of complementary programs each targeting a specific subpopulation or issue.

Identifying Empirical Support for First Responder Mental Health Interventions

Another consideration for Congress involves the degree of empirical support for first responder mental health programs. Not all post-crisis or trauma-based interventions have been found to be safe and effective. Research remains mixed on the effectiveness of certain treatments, with some studies suggesting that some interventions—such as particular crisis response programs—may actually promote harm. For example, some studies have found that Critical Incident Stress Debriefing (CISD), which is used after a traumatic event, may prevent symptoms of post-traumatic stress disorder,⁶⁵ while other studies suggest it is ineffective and may even increase the risk of PTSD.⁶⁶ When supporting mental health interventions for first responders, Congress might consider the empirical support for such programs and promote the use of evidence-based practices. The attention paid toward first responder mental health is relatively new. Given the dearth of research, federal funding for studies on mental health treatments for first responders may help identify effective programs specifically for this population. Databases to help track first responder mental health could also help identify areas most in need. Similarly, agencies focusing on mental health—such as SAMHSA and NIMH—could play more significant roles in addition to the agencies primarily responsible for each specific occupation. This may be achieved through joint grant programs or joint research, and through coordination of research priorities and joint publication of findings.

Coordinating First Responder Mental Health Programs across Agencies

In considering support for first responder mental health, Congress may determine how to organize and execute these programs on a federal level. Currently, most federal activities involving first responders are single programs for individual occupations or specific agency (e.g., police officers, firefighters, or EMS) workforces. Some federal programs do not target mental health specifically either, but rather could be used for mental health-related activities, among other allowable uses. While Congress has provided some funding for mental health programs and services for first responders, funding has been piecemeal, spread across many federal agencies and many grant programs. As a result, some mental health advocates have called for a more coordinated approach to provide accessible, quality care for first responders. Congress could consider whether to continue individual program administration through executive departments of jurisdiction, or establish a more coordinated or centralized approach. One of the challenges with this approach is the decentralized nature of the first responder system, and the diversity of first responder agencies. Some law enforcement agencies—such as police departments in populous metropolitan areas—may be large public institutions, while rural fire departments, for example, may be much smaller and composed almost entirely of volunteers. Effective mental health programs would need to consider the diversity in these agencies and provide enough flexibilities to meet the needs of the various first responder organizations.

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