Social Support, Stress, and Suicidal Ideation in Professional Firefighters Grace Stephanie J. Carpenter, BA; Thomas P. Carpenter, MA; Nathan A. Kimbrel, PhD; Elisa J. Flynn, MA; Michelle L. Pennington, BA; Claire Cammarata, PhD; Rose T. Zimering, PhD; Barbara W. Kamholz, PhD; Suzy B. Gulliver, PhD Objective: To hypothesize that social support may protect against the effect of firefighter stress on suicidal ideation. Methods: Overall, 334 firefighters completed measures of occupational stress, social support, and suicidal ideation. Results: At high levels of social support, no association was observed between occupational stress and suicidal ideation (ϕ= -.06, ns); however, when social support was low, oc-
S
uicide was the tenth leading cause of death in the United States (US) in 20101 and has become a major concern among professional firefighters in recent years.2 Past research indicates that suicide is associated with a variety of factors, including behavioral health disorders,3,4 impulsivity,5,6 hopelessness,7,8 and suicidal ideation.9-11 Among US adults, lifetime prevalence rates for suicidal ideation are estimated to range from 5% to 14%, whereas 12-month prevalence rates are estimated to range from 2% to 10%.12 Suicide rates within fire service have been considerably more difficult to study.2 For example, as Gist et al2 note, occupation is not always recorded on death certificates. Moreover, given that a significant portion of American firefighters are volunteers, even tracking occupation would be inadequate for accurate identification of many firefighter suicides. In addition, differentiating between suicide and accidental death can be challenging. Thus, despite the importance of the issue, suicidality in firefightGrace Stephanie J. Carpenter, Research Assistant, Elisa J. Flynn, Research Associate, Michelle L. Pennington, Research Assistant, and Suzy B. Gulliver, Director, Baylor Scott & White Warriors Research Institute, Waco, TX. Thomas P. Carpenter, Instructor, Seattle Pacific University, Seattle, WA. Nathan A. Kimbrel, Principal Investigator, Durham Veterans Affairs (VA) Medical Center, Durham, NC. Claire Cammarata, Clinical Director, New York City Fire Department Counseling Services Unit, New York City, NY. Rose Zimering, Director of Outpatient Mental Health, and Barbara W. Kamholz, Associate Director of Outpatient Mental Health, VA Boston Healthcare System, Boston, MA. Correspondence Dr Gulliver; [email protected]
Am J Health Behav.™ 2015;39(2):191-196
cupational stress showed a positive association with suicidal ideation (ϕ = .16, p < .05). Conclusions: The association between occupational stress and suicidal ideation may be reduced by social support. Further research on this topic is warranted. Key words: suicidal ideation; social support; stress; firefighters Am J Health Behav. 2015;39(2):191-196 DOI: http://dx.doi.org/10.5993/AJHB.39.2.5
ers has received little empirical attention, making it an important, yet understudied issue. Recently, the National Volunteer Fire Council (NVFC)13 conducted a survey study of more than 800 firefighters. They found that approximately 1 in 4 professional career firefighters (25.1%) had considered suicide during their career in fire service, whereas approximately 1 in 5 (18.4%) volunteer firefighters had. Thus, whereas these findings are preliminary, they suggest that suicidal ideation may be elevated among firefighters. There are a number of other reasons to suspect that firefighters might be at increased risk for suicide. For example, white males make up a large proportion of fire service and also represent one of the highest risk demographic groups for completed suicide.12 Indeed, it is estimated that more than 70% of suicides in the United States are completed by white males.2 Behavioral health disorders, such as depression, posttraumatic stress disorder (PTSD), and alcohol use disorders, are also associated with increased risk for suicidality,3,4 and this association is also present among firefighters.13 This association is particularly relevant for firefighters, however, as there is evidence that firefighters are at elevated risk for these and other behavioral health problems,13-19 perhaps due to their high levels of occupational stress17,20 and routine exposure to potentially traumatic experiences.18,21-24 There is also some evidence to suggest that low levels of social support are associated with increased risk for behavioral health problems among firefighters, particularly when firefighters are also high on self-blame.14 Finally, firefighters
191
Social Support, Stress, and Suicidal Ideation in Professional Firefighters might be at higher risk of attempting or completing suicide following suicidal ideation due to an increased capability for suicide that results from exposure to repeated threats to both their own and others’ lives;2,25 however, additional research is needed on this important topic. Stress, Social Support, and Suicidality As noted above, firefighting is associated with a unique set of occupational stressors.17,18,20 Given that higher levels of stress are known to increase the risk of suicide in general,26-29 it is likely that stress also may be a risk factor for suicidal ideation among firefighters, and there is some evidence to support this idea.13 For example, the large survey of firefighters conducted by NVFC13 found that perceived stress has a positive association with suicidality (OR = 1.14, p < .001). At the same time, social support appears to be a protective factor against suicide. Joiner’s interpersonal-psychological theory of suicide30 posits that suicidal behavior results from thwarted belongingness (a belief that one is alone and no longer connected to others and that the world would be better off without one’s presence) accompanied by a disinhibition toward pain and annihilation. This suggests that social connectedness could be an important protective factor for individuals who are at risk. Substantial empirical evidence suggests that social support is an important protective factor. For example, a meta-analysis by Prati and Pietrantoni31 concluded that the mean effect of social support on mental health outcomes was r = .27, and Pienaar, Rothmann, and van de Vijver32 found that social support seeking was negatively associated with suicidality among police and first responders. There is also some evidence to suggest that social support may moderate the effects of other variables, such as PTSD and depression symptom severity, on suicidal ideation.33 Study Objective Although there has been some research on the relationship between social support and mental health problems among firefighters,14,20 to date, no study has examined whether social support moderates the effects of occupational stress on firefighters. As Nock et al12 argue, more research is needed to understand those factors that protect against the deleterious effects of stress and to improve understanding of how protective factors guard against suicidality. As noted above, DeBeer et al33 reported that social support (a protective factor) moderated the effect of posttraumatic stress disorder (PTSD) and depressive (MDD) symptoms (a risk factor) among a sample of returning Iraq/ Afghanistan veterans. When social support was high, there was not a significant association between PTSD-MDD symptoms and stress; however, when social support was low, there was a strong positive association between PTSD-MDD symptoms and suicidal ideation, suggesting that social
192
support buffered the effects of PTSD-MDD symptoms on veterans’ level of suicidal ideation. The objective of our research was to examine if social support might play a similar role among firefighters and buffer firefighters against the deleterious effects of high levels of occupational stress. Thus, we hypothesized that occupational stress would be associated with suicidal ideation among professional firefighters only when social support was low. When social support was high, we expected to find no association between occupational stress and suicidal ideation. METHOD Participants and Procedures Overall, 334 professional firefighters who participated in 2 separate studies were included in the current analyses. A total of 172 firefighters came from the first project, funded by FEMA to assess the effects of a training program aimed at increasing behavioral health utilization among firefighters. The second study was a treatment development study aimed at examining a treatment adaptation of cognitive-behavioral therapy for acute stress disorder.14 In both cases, participants completed the measures included in the current study as part of their baseline assessments before any training or treatment procedures had taken place. Participants in both studies were recruited through outreach to firehouses in one of 3 US cities. The first city was located in the Northeast, the second city was located in the Southeast, and the third city was located in the Southwest. Participation was voluntary and participants were compensated for their time. Informed consent was obtained from all participants prior to their participation, and Institutional Review Board approval was received prior to the collection of any data. Firefighters were consented privately, but completed the self-report questionnaires in group settings under the supervision of a doctoral level clinical psychologist. Measures The Sources of Occupational Stress Scale—14 (SOOS-14)20 is a 14-item self-report measure adapted from Beaton and Murphy’s17 Sources of Occupational Stress scale designed to assess occupational stressors in firefighters and paramedics. The SOOS-14 is an abbreviated version of the original 57-item measure. The SOOS-14 has demonstrated good reliability and validity in previous research with firefighters.20 Internal consistency for the SOOS-14 in the current study was .90 (.78 in Sample 1 and .86 in Sample 2). Social support was assessed in 2 ways. In Sample 1 the Firefighter Social Support Scale (SSS-FF; Gulliver et al, unpublished measure) was used, a 9-item self-report measure based on the Social Support scale of the Deployed Risk and Resilience Inventory.34 The SSS-FF was adapted from this 15item measure to include only the items relevant to firefighters. The SSS-FF assesses the amount
Carpenter et al
Table 1 Participant Characteristics Characteristic
Sample 1 N = 172
Sample 2 N = 162
All participants N = 334
Age (mean y ± SD)
38.7 ± 7.4
41.4 ± 8.4
40.0 ± 7.9
Female
19.8 (34)
0.6 (1)
10.5 (35)
Caucasian
72.7 (125)
56.8 (92)
65.0 (217)
African-American
18.0 (31)
30.9 (50)
24.3 (81)
Latino
19.7 (34)
9.8 (16)
15.0 (50)
Years of Education (mean years ± SD)
14.3 ± 2.0
13.2 ± 1.6
13.8 ± 1.8
Married or Cohabitating
59.3 (102)
72.8 (118)
65.9 (220)
Firefighter
72.7 (125)
79.0 (128)
75.7 (253)
Officer
25.0 (43)
21.0 (34)
23.1 (77)
Rank
Note. Data presented as % (N), except where otherwise noted.
of social support participants received from their co-workers over the past 4 months. Cronbach’s alpha for the SSS-FF was .81. In Sample 2, the Interpersonal Support Evaluation List35 was used, a 40-item self-report measure of the perceived availability of social support. Cronbach’s alpha for the ISEL was .94. Suicidal ideation was assessed using the ideation item on 2 similar measures of depression. Sample 2 completed the Beck Depression Inventory – II (BDI-II36), a 21-item self-report instrument. Sample 1 completed the Beck Depression Inventory for Primary Care (BDI-PC37), a 7-item short form measure used for screening purposes. Both scales utilized the same suicidal ideation item. Participants were given 4 ordinal response options: “I don’t have any thoughts of killing myself,” “I have thoughts of killing myself, but I would not carry them out,” “I would like to kill myself,” and “I would kill myself if I had the chance.” Only the first 2 options were endorsed, with relatively low levels across both samples (Table 1). Consequently, participants received a dichotomous score for suicidal ideation as either present or absent.
encountered issues estimating a moderation model given the low variance in suicidal ideation. In the resulting dataset, each participant had dichotomous scores for social support (scored as high/ low), occupational stress (scored as high/low), and suicidal ideation (scored as present/absent). The data were subjected to a suicidal ideation (present/absent) × social support (low/high) × occupational support (low/high) contingency table analysis. Counts for these data are depicted in Table 2. For all analyses, traditional chi-square tests and p-values are calculated. Because of low expected frequencies, these analyses were supplemented by the more conservative Fisher’s exact test. In the present analyses, both are reported and point to the same general conclusions in the data.
Data Analysis Plan In order to combine the data across samples, the scores for the social support and occupational stress measures were first z-scored within each of the samples. Participants were then dichotomized into “high” and “low” groups based on their z-scores using a mean split. Prior to combining the samples, we tested to see whether or not the 2 samples differed significantly on the key measures and found that there were no significant differences (p’s > .05). Non-parametric contingency table analysis was used for the analysis because maximum-likelihood-based procedures (eg, logistic regression)
RESULTS A table of descriptive statistics for each sample is shown in Table 1. An omnibus analysis of the table indicated that one or more variables were related, χ2(1) = 5.15, p = .02, Fisher’s exact p = .03. Overall analyses also indicated that there was a positive association between occupational stress and suicidal ideation, ϕ = .13, χ2(1) = 5.10, p = .02, Fisher’s exact p = .035. This indicates that suicidal ideation had a positive association with on-the-job stress for fire service professionals. Overall analyses also indicated that peer social support was correlated with decreased suicidal ideation, ϕ = -.14, χ2(1) = 6.78, p = .009, Fisher’s exact p = .01. This indicates that firefighter peer social support was associated with decreased suicidal ideation. According to the stress-buffering hypothesis, we predicted that the relationship between stress and suicidal ideation would differ as a function of peer social support. To test this, the association between stress and suicidal ideation was estimated
Am J Health Behav.™ 2015;39(2):191-196
DOI:
http://dx.doi.org/10.5993/AJHB.39.2.5
193
Social Support, Stress, and Suicidal Ideation in Professional Firefighters
Table 2 Cross Tabulation of Suicidal Ideation, Occupational Stress, and Peer Social Support Occupational Stress Social Support
Suicidal Ideation
Below Median
Above Median
Φ
Below Median
None (
S
uicide was the tenth leading cause of death in the United States (US) in 20101 and has become a major concern among professional firefighters in recent years.2 Past research indicates that suicide is associated with a variety of factors, including behavioral health disorders,3,4 impulsivity,5,6 hopelessness,7,8 and suicidal ideation.9-11 Among US adults, lifetime prevalence rates for suicidal ideation are estimated to range from 5% to 14%, whereas 12-month prevalence rates are estimated to range from 2% to 10%.12 Suicide rates within fire service have been considerably more difficult to study.2 For example, as Gist et al2 note, occupation is not always recorded on death certificates. Moreover, given that a significant portion of American firefighters are volunteers, even tracking occupation would be inadequate for accurate identification of many firefighter suicides. In addition, differentiating between suicide and accidental death can be challenging. Thus, despite the importance of the issue, suicidality in firefightGrace Stephanie J. Carpenter, Research Assistant, Elisa J. Flynn, Research Associate, Michelle L. Pennington, Research Assistant, and Suzy B. Gulliver, Director, Baylor Scott & White Warriors Research Institute, Waco, TX. Thomas P. Carpenter, Instructor, Seattle Pacific University, Seattle, WA. Nathan A. Kimbrel, Principal Investigator, Durham Veterans Affairs (VA) Medical Center, Durham, NC. Claire Cammarata, Clinical Director, New York City Fire Department Counseling Services Unit, New York City, NY. Rose Zimering, Director of Outpatient Mental Health, and Barbara W. Kamholz, Associate Director of Outpatient Mental Health, VA Boston Healthcare System, Boston, MA. Correspondence Dr Gulliver; [email protected]
Am J Health Behav.™ 2015;39(2):191-196
cupational stress showed a positive association with suicidal ideation (ϕ = .16, p < .05). Conclusions: The association between occupational stress and suicidal ideation may be reduced by social support. Further research on this topic is warranted. Key words: suicidal ideation; social support; stress; firefighters Am J Health Behav. 2015;39(2):191-196 DOI: http://dx.doi.org/10.5993/AJHB.39.2.5
ers has received little empirical attention, making it an important, yet understudied issue. Recently, the National Volunteer Fire Council (NVFC)13 conducted a survey study of more than 800 firefighters. They found that approximately 1 in 4 professional career firefighters (25.1%) had considered suicide during their career in fire service, whereas approximately 1 in 5 (18.4%) volunteer firefighters had. Thus, whereas these findings are preliminary, they suggest that suicidal ideation may be elevated among firefighters. There are a number of other reasons to suspect that firefighters might be at increased risk for suicide. For example, white males make up a large proportion of fire service and also represent one of the highest risk demographic groups for completed suicide.12 Indeed, it is estimated that more than 70% of suicides in the United States are completed by white males.2 Behavioral health disorders, such as depression, posttraumatic stress disorder (PTSD), and alcohol use disorders, are also associated with increased risk for suicidality,3,4 and this association is also present among firefighters.13 This association is particularly relevant for firefighters, however, as there is evidence that firefighters are at elevated risk for these and other behavioral health problems,13-19 perhaps due to their high levels of occupational stress17,20 and routine exposure to potentially traumatic experiences.18,21-24 There is also some evidence to suggest that low levels of social support are associated with increased risk for behavioral health problems among firefighters, particularly when firefighters are also high on self-blame.14 Finally, firefighters
191
Social Support, Stress, and Suicidal Ideation in Professional Firefighters might be at higher risk of attempting or completing suicide following suicidal ideation due to an increased capability for suicide that results from exposure to repeated threats to both their own and others’ lives;2,25 however, additional research is needed on this important topic. Stress, Social Support, and Suicidality As noted above, firefighting is associated with a unique set of occupational stressors.17,18,20 Given that higher levels of stress are known to increase the risk of suicide in general,26-29 it is likely that stress also may be a risk factor for suicidal ideation among firefighters, and there is some evidence to support this idea.13 For example, the large survey of firefighters conducted by NVFC13 found that perceived stress has a positive association with suicidality (OR = 1.14, p < .001). At the same time, social support appears to be a protective factor against suicide. Joiner’s interpersonal-psychological theory of suicide30 posits that suicidal behavior results from thwarted belongingness (a belief that one is alone and no longer connected to others and that the world would be better off without one’s presence) accompanied by a disinhibition toward pain and annihilation. This suggests that social connectedness could be an important protective factor for individuals who are at risk. Substantial empirical evidence suggests that social support is an important protective factor. For example, a meta-analysis by Prati and Pietrantoni31 concluded that the mean effect of social support on mental health outcomes was r = .27, and Pienaar, Rothmann, and van de Vijver32 found that social support seeking was negatively associated with suicidality among police and first responders. There is also some evidence to suggest that social support may moderate the effects of other variables, such as PTSD and depression symptom severity, on suicidal ideation.33 Study Objective Although there has been some research on the relationship between social support and mental health problems among firefighters,14,20 to date, no study has examined whether social support moderates the effects of occupational stress on firefighters. As Nock et al12 argue, more research is needed to understand those factors that protect against the deleterious effects of stress and to improve understanding of how protective factors guard against suicidality. As noted above, DeBeer et al33 reported that social support (a protective factor) moderated the effect of posttraumatic stress disorder (PTSD) and depressive (MDD) symptoms (a risk factor) among a sample of returning Iraq/ Afghanistan veterans. When social support was high, there was not a significant association between PTSD-MDD symptoms and stress; however, when social support was low, there was a strong positive association between PTSD-MDD symptoms and suicidal ideation, suggesting that social
192
support buffered the effects of PTSD-MDD symptoms on veterans’ level of suicidal ideation. The objective of our research was to examine if social support might play a similar role among firefighters and buffer firefighters against the deleterious effects of high levels of occupational stress. Thus, we hypothesized that occupational stress would be associated with suicidal ideation among professional firefighters only when social support was low. When social support was high, we expected to find no association between occupational stress and suicidal ideation. METHOD Participants and Procedures Overall, 334 professional firefighters who participated in 2 separate studies were included in the current analyses. A total of 172 firefighters came from the first project, funded by FEMA to assess the effects of a training program aimed at increasing behavioral health utilization among firefighters. The second study was a treatment development study aimed at examining a treatment adaptation of cognitive-behavioral therapy for acute stress disorder.14 In both cases, participants completed the measures included in the current study as part of their baseline assessments before any training or treatment procedures had taken place. Participants in both studies were recruited through outreach to firehouses in one of 3 US cities. The first city was located in the Northeast, the second city was located in the Southeast, and the third city was located in the Southwest. Participation was voluntary and participants were compensated for their time. Informed consent was obtained from all participants prior to their participation, and Institutional Review Board approval was received prior to the collection of any data. Firefighters were consented privately, but completed the self-report questionnaires in group settings under the supervision of a doctoral level clinical psychologist. Measures The Sources of Occupational Stress Scale—14 (SOOS-14)20 is a 14-item self-report measure adapted from Beaton and Murphy’s17 Sources of Occupational Stress scale designed to assess occupational stressors in firefighters and paramedics. The SOOS-14 is an abbreviated version of the original 57-item measure. The SOOS-14 has demonstrated good reliability and validity in previous research with firefighters.20 Internal consistency for the SOOS-14 in the current study was .90 (.78 in Sample 1 and .86 in Sample 2). Social support was assessed in 2 ways. In Sample 1 the Firefighter Social Support Scale (SSS-FF; Gulliver et al, unpublished measure) was used, a 9-item self-report measure based on the Social Support scale of the Deployed Risk and Resilience Inventory.34 The SSS-FF was adapted from this 15item measure to include only the items relevant to firefighters. The SSS-FF assesses the amount
Carpenter et al
Table 1 Participant Characteristics Characteristic
Sample 1 N = 172
Sample 2 N = 162
All participants N = 334
Age (mean y ± SD)
38.7 ± 7.4
41.4 ± 8.4
40.0 ± 7.9
Female
19.8 (34)
0.6 (1)
10.5 (35)
Caucasian
72.7 (125)
56.8 (92)
65.0 (217)
African-American
18.0 (31)
30.9 (50)
24.3 (81)
Latino
19.7 (34)
9.8 (16)
15.0 (50)
Years of Education (mean years ± SD)
14.3 ± 2.0
13.2 ± 1.6
13.8 ± 1.8
Married or Cohabitating
59.3 (102)
72.8 (118)
65.9 (220)
Firefighter
72.7 (125)
79.0 (128)
75.7 (253)
Officer
25.0 (43)
21.0 (34)
23.1 (77)
Rank
Note. Data presented as % (N), except where otherwise noted.
of social support participants received from their co-workers over the past 4 months. Cronbach’s alpha for the SSS-FF was .81. In Sample 2, the Interpersonal Support Evaluation List35 was used, a 40-item self-report measure of the perceived availability of social support. Cronbach’s alpha for the ISEL was .94. Suicidal ideation was assessed using the ideation item on 2 similar measures of depression. Sample 2 completed the Beck Depression Inventory – II (BDI-II36), a 21-item self-report instrument. Sample 1 completed the Beck Depression Inventory for Primary Care (BDI-PC37), a 7-item short form measure used for screening purposes. Both scales utilized the same suicidal ideation item. Participants were given 4 ordinal response options: “I don’t have any thoughts of killing myself,” “I have thoughts of killing myself, but I would not carry them out,” “I would like to kill myself,” and “I would kill myself if I had the chance.” Only the first 2 options were endorsed, with relatively low levels across both samples (Table 1). Consequently, participants received a dichotomous score for suicidal ideation as either present or absent.
encountered issues estimating a moderation model given the low variance in suicidal ideation. In the resulting dataset, each participant had dichotomous scores for social support (scored as high/ low), occupational stress (scored as high/low), and suicidal ideation (scored as present/absent). The data were subjected to a suicidal ideation (present/absent) × social support (low/high) × occupational support (low/high) contingency table analysis. Counts for these data are depicted in Table 2. For all analyses, traditional chi-square tests and p-values are calculated. Because of low expected frequencies, these analyses were supplemented by the more conservative Fisher’s exact test. In the present analyses, both are reported and point to the same general conclusions in the data.
Data Analysis Plan In order to combine the data across samples, the scores for the social support and occupational stress measures were first z-scored within each of the samples. Participants were then dichotomized into “high” and “low” groups based on their z-scores using a mean split. Prior to combining the samples, we tested to see whether or not the 2 samples differed significantly on the key measures and found that there were no significant differences (p’s > .05). Non-parametric contingency table analysis was used for the analysis because maximum-likelihood-based procedures (eg, logistic regression)
RESULTS A table of descriptive statistics for each sample is shown in Table 1. An omnibus analysis of the table indicated that one or more variables were related, χ2(1) = 5.15, p = .02, Fisher’s exact p = .03. Overall analyses also indicated that there was a positive association between occupational stress and suicidal ideation, ϕ = .13, χ2(1) = 5.10, p = .02, Fisher’s exact p = .035. This indicates that suicidal ideation had a positive association with on-the-job stress for fire service professionals. Overall analyses also indicated that peer social support was correlated with decreased suicidal ideation, ϕ = -.14, χ2(1) = 6.78, p = .009, Fisher’s exact p = .01. This indicates that firefighter peer social support was associated with decreased suicidal ideation. According to the stress-buffering hypothesis, we predicted that the relationship between stress and suicidal ideation would differ as a function of peer social support. To test this, the association between stress and suicidal ideation was estimated
Am J Health Behav.™ 2015;39(2):191-196
DOI:
http://dx.doi.org/10.5993/AJHB.39.2.5
193
Social Support, Stress, and Suicidal Ideation in Professional Firefighters
Table 2 Cross Tabulation of Suicidal Ideation, Occupational Stress, and Peer Social Support Occupational Stress Social Support
Suicidal Ideation
Below Median
Above Median
Φ
Below Median
None (
