Considering the effects of stress on well-being, first responders are at higher risk of suffering from emotional fallout from their work. However, new research in this area suggests the extent is striking.

Investigators from Syracuse University concluded EMS workers face as much as three times the risk for significant mental health problems vs. the general population.1 The good news is there are some straightforward solutions that could mitigate the harmful effects of stress and reduce their risk of developing depression, PTSD, or other mental health problems.

While these are early days in what investigators hope to be a longer-term project, they have uncovered a few concrete steps EMS workers and their colleagues can take to counter the harmful effects of their often highly charged work activities.

Bryce Hruska, PhD, assistant professor at Syracuse, says addressing the stressors and mental health challenges EMS workers face has been on his radar for a long time. “A lot of our research is focused on patient populations, but over the last several years I have been focused on occupational populations ... and EMTs in particular,” he says. The most recognized risk factor facing EMTs relates to the kinds of critical events to which they respond. “These are events that may involve patient deaths [and/or] a threat of harm to other patients or even the EMTs themselves,” Hruska observes. “What we know from the broader trauma literature is that these types of events are really distressing and difficult for all people to cope with. EMTs experience these events on a regular basis.”

Hruska and a colleague recruited 79 EMS workers from a provider in central New York to complete a daily assessment of occupational stressors, along with measurements of PTSD and depression symptom severity. The assessment also included questions about sleep efficiency and social conflicts. In addition, respondents provided input on any social support they received, recovery activities in which they engaged, and any meaning or positive social impact they perceived coming from their work.

“We collected the data for eight days. We found that almost two-thirds of the people in the study experienced one [highly stressful, critical event] just over the course of eight days,” Hruska reports. “If you extrapolate that out to the whole year, it ends up being 29 events per year, and that is for each person.” On top of experiencing frequent critical events, EMTs typically work demanding schedules, often enduring day-long shifts on little sleep. Hruska believes this produces “a cumulative effect,” which was evident in the study.

For instance, the researchers reported each additional work demand or critical event an EMS worker experienced on a given work day was associated with a 5% increase in their PTSD symptom severity levels that day. Each social conflict was associated with a 12% increase in their depression symptom severity level.

While the research was conducted in 2019, the COVID-19 pandemic only heightened the worry and stress for EMTs. “We had a lot of existing public health problems, and COVID made a lot of them worse,” Hruska shares, noting in particular the rise in overdose deaths and general violence.

Understanding the challenges EMS workers face was an important aspect of the study, Hruska also studied what kinds of behaviors or activities EMS workers already are engaging in to navigate these challenges.

“People who found some meaning in the day’s challenges ... that is one thing that we found was protective and helped people’s mental health,” Hruska says. For example, if an EMT was in conflict with a colleague, the worker would think about how he could improve his communication tactics for the next day, rather than just stewing about a negative situation. In other cases, workers would find some helpful lesson or pointer from their work that day that could help them improve.

Investigators also identified what they refer to as recovery activities, specific behaviors that proved protective of well-being. These included social activities such as sharing a meal with other people at the end of a shift.

“After people experience stressful events, the social support that occurs in the aftermath can be very helpful,” Hruska notes. EMS workers can use this fellowship to conceptualize stress and potentially draw meaning from the stressful event. Similarly, exercising or playing a sport was associated with a reduction in depression and stress-related symptoms each day. “We know that when people respond to stressful events, they’ve got a lot of physiological activation,” Hruska notes. “Exercise or sports activities can allow you to expend that physiological drive and get back to a kind of baseline level of functioning.”

While individual EMS workers can take it upon themselves to engage in recovery activities, EMS leaders can help, too. Hruska suggests that in the aftermath of a critical event, set aside dedicated down time. “This provides time for workers to recover and to make sense of the event,” Hruska says. “It is also helpful to do some form of internal debrief after a bit of time has passed.”

Hruska also suggests putting policies in place that promote healthy behaviors. “Exercise is a big one, and we know it is important for a variety of reasons,” he says. “Some EMS agencies have dedicated space so that workers can exercise in between shifts or before or after a shift.” Such spaces can serve the dual purpose of promoting exercise while also providing an area where workers can socialize.

EMS leaders also should consider the finding that social conflicts can cause a spike in depression symptoms among EMS workers.

“These involved conflicts that would occur during the day with co-workers, supervisors, or ... people who are not at work,” Hruska shares. “One potential actionable item for employers is to find some ways to promote or refine communication strategies that are used between workers.” Hruska suggests thinking about ways to facilitate proactive, healthy communication when EMS staff members are working through various stressful situations.

Building on the findings of this research, investigators hope to turn their attention to creating tools that EMS workers and leaders can use to nurture overall worker well-being. “The plan is to try a brief intervention where we have workers think about the challenges they experience during the day, and kind of guide them toward finding some meaning that they can extract from them,” Hruska explains.

Further, Hruska wants to pair this intervention with methods to promote the beneficial recovery activities that were highlighted in the first phase of the research. “We know that when people do more of these recovery activities they also have different psychological experiences that may be helpful,” he notes.


  1. Hruska B, Barduhn M. Dynamic psychosocial risk and protective factors associated with mental health in Emergency Medical Service (EMS) personnel. J Affect Disord 2021;282:9-17.