Quality of Life Research

, Volume 16, Issue 8, pp 1289–1297

The relationship between quality of life and posttraumatic stress disorder or major depression for firefighters in Kaohsiung, Taiwan

Authors

  • Yong-Shing Chen
    • Department of Community PsychiatryKai-Suan Psychiatric Hospital
  • Ming-Chao Chen
    • Department of Community PsychiatryKai-Suan Psychiatric Hospital
    • Department of Community PsychiatryKai-Suan Psychiatric Hospital
    • Department of Heath Care Administration, NursingI-Shou University
  • Feng-Ching Sun
    • Department of NursingKai-Suan Psychiatric Hospital
  • Pei-Chun Chen
    • Department of Community PsychiatryKai-Suan Psychiatric Hospital
  • Kuan-Yi Tsai
    • Department of Community PsychiatryKai-Suan Psychiatric Hospital
  • Shin-Shin Chao
    • Department of Community PsychiatryKai-Suan Psychiatric Hospital
Original Paper

DOI: 10.1007/s11136-007-9248-7

Cite this article as:
Chen, Y., Chen, M., Chou, F.H. et al. Qual Life Res (2007) 16: 1289. doi:10.1007/s11136-007-9248-7

Abstract

Objective

The work of firefighters involves the risk of exposure to the harmful effects of toxic substances as well as the possibility of enormous emotional shock from disasters, which may result in psychiatric impairments and a lower quality of life. Therefore, we examined quality of life, prevalence of posttraumatic stress disorder (PTSD) and major depression, and the related risk factors for firefighters in Kaohsiung, Taiwan.

Methods

This is a two-stage survey study. During the first stage, we used the 36-item Short-Form Health Survey (SF-36) and the Disaster-Related Psychological Screening Test (DRPST) to assess quality of life, probable PTSD, probable major depression, and the related risk factors for 410 firefighters. During the second stage, psychiatrists categorized these probable cases according to self-reported questionnaires against DSM-IV into PTSD or major depression group, subclinical group, and health group. All the data were analyzed with SPSS 10.0 Chinese version.

Results

The estimated current prevalence rates for major depression and PTSD were 5.4% (22/410) and 10.5% (43/410), respectively. The firefighters with estimated PTSD or major depression scored significantly lower on quality of life measures than subclinical PTSD/major depression and mentally healthy groups, which was evident in eight concepts and two domains of the SF-36. The major predictors of poor quality of life and PTSD/major depression were mental status, psychosocial stressors, or perceived physical condition.

Conclusion

Firefighters have a higher estimated rate of PTSD, and the risk factors that affect quality of life and PTSD/major depression should encourage intervention from mental health professionals.

Keywords

FirefightersPosttraumatic stress disorder (PTSD)Major depressionQuality of life36-Item Short-Form Health Survey (SF-36)Disaster-Related Psychological Screening Test (DRPST)

Introduction

During the past several decades, concern about stress in the workplace has grown considerably [13]. Certain aspects of work, such as high demand/low self-control, or experience with enormous disasters are considered to contribute to highly stressful jobs. Work stress may result in high rates of job dissatisfaction, early retirement, high accident rates, and poor physical and mental health [23]. Among the mental health problems associated with stress, depression and PTSD are two major issues of public concern. Rescue workers, such as firefighters, are exposed to the harmful effects of toxic substances as well as at risk for enormous emotional shock when disasters occur (e.g. firefighters who entered the World Trade Center ruin after the 9/11 terrorist attacks) [4]. Indeed, disaster rescue work is associated with a high level of stress even for highly trained professionals and may lead to mental health problems [3, 56]. However, this group has been less likely to seek social support, medical treatment, or psychotherapy in the past decades.

Tragic events such as the 9/11 terrorist attacks, the Southern Asia tsunami, or catastrophic earthquakes, have highlighted the importance of understanding the effects of trauma on disaster workers [7]. For example, 16.7–19.3% of rescue workers experienced psychiatric diseases and 21.4% had PTSD after the impact of a catastrophic earthquake, in Taiwan [8]. Fullerton et al. [9] found that 13 months later, disaster workers had significantly higher rates of PTSD and depression than comparison subjects and those who were young and single were more likely to develop acute stress disorders. Those with high exposure and previous disaster experience, or who had acute stress disorders, were more likely to develop PTSD. North et al. [10] found that high rates of alcohol disorders were seen among all firefighters in Oklahoma City. Another work impact is related to poor quality of life and those with poorer quality of life are less likely to return to work [3, 11]. Our previous studies [3, 12, 13] also reported that major life stresses contribute to depression, and depressive illness is often accompanied by marked reductions in quality of life. The PTSD patients had similar results [1214]. Therefore, documenting psychosocial stressors and assessing the functional indices of illness that affect quality of life may be advantageous. According to the 2005 annual health report of the Department of Health, Taiwan, the overall suicide rate was 18.8 per 100,000, and the suicide rate in Kaohsiung was higher than that in Taiwan. As we know, most people have a relatively higher probability of depression before suicide. Therefore, an exploration of the risk factors for depression may be helpful in suicide prevention. As a result, the Kaohsiung government encouraged high-risk groups such as firefighters to receive mental health examinations and promotions from the health care system since 2005. According to Hobfoll’s conservation of resources stress theory [15], resource loss is an important determinant of individual stress, physical and mental health. Therefore, early detection and early treatment of firefighters with mental illness and the removal or decrease of stressors are important actions needed to decrease individual suffering as well as economic burdens or other stressors on the family and society. Therefore, our mental health examination included the subjects’ demographic data, perceived physical problems, psychosocial stressors, mental illness assessment, and quality of life scores. If subjects had suspected mental illness, they were requested to take part in the 2nd stage survey for further management. The study is part of a mental health promotion in Kaohsiung, and the purpose of this study is to investigate the impact on quality of life, the prevalence of posttraumatic stress disorder (PTSD)/major depression, and the related risk factors as determined from part of a mental health examination for firefighters in Kaohsiung city, Taiwan.

Methods

Location

In 2006, Kaohsiung city had a population of 1.54 million and a staff of about 643 in the Fire Bureau. Situated on the southwest coast of Taiwan with a geographic area of 153.6 sq km, Kaohsiung city is the largest commercial harbor and the second-largest city in Taiwan.

Instruments

The DRPST developed by Chou et al. [16] is a rapid screening scale for major depression (MD) and posttraumatic stress disorder (PTSD). It was designed initially for effective and rapid screening of MD and PTSD for disaster survivors; it is also suitable for the general population based on DSM-IV criteria [3]. The first part of the DRPST is used to compile background information, including age, gender, education, marital status, perceived mental status, perceived physical condition, and associated risk factors for mental illness. The second part investigates the psychological symptoms of MD and PTSD based on DSM-IV criteria and is validated by psychiatrists [16]. For MD detection, a three-symptom scale was selected according to DSM-IV criteria of MD. A score of 2 or higher on the MD scale was used to define probable positive cases of MD, giving a sensitivity of 92.1%, specificity of 98.3%, positive predictive value of 83.3%, and negative predictive value of 99.3% as compared to the Mini-International Neuropsychiatric Interview. A 7-symptom scale was selected for PTSD screening. Scores of 4 or higher on the PTSD scale were used to define probable positive cases of PTSD. Compared with PTSD diagnosed by psychiatrists with the MINI, its sensitivity was 76.1%, specificity was 99.8%, positive predictive value was 97.2%, and negative predictive value was 97.4% [16]. During the second stage, psychiatrists categorized these self-report questionnaire cases into three groups according to the DSM-IV classification: PTSD and major depression group, subclinical group and health group.

We removed the questions correlated to disasters such as physical injury or economic loss suffered as a result of an earthquake and modified the DRPST to collect demographic and psychosocial data in three parts: (1) basic demographic data including age, sex, education level, number of past traumatic events, and psychophysiolgical problems (such as sleep disturbance, etc.), (2) perceived current physical problems such as genitourinary, cardiovascular, gastrointestinal, sensory, respiratory, or musculoskeletal and skin system, and (3) three dimensions of stress: financial problems, family problems, and work stress. A checklist with “yes” or “no” questions collected the information on stress. Family problems included marital status, discord in the marriage, family conflict, and parenting problems. Work stress included performance that was based on work overload stress, and criticism due to work performance etc. [3].

The SF-36 is one of the most commonly used Health Related Quality of Life (HRQoL) questionnaires. It has become widely used in community-based health surveys and outcome assessment of physical and mental illnesses because of its brevity and psychometric performance. The SF-36 incorporates two dimensions: a physical component summary (PCS) and a mental component summary (MCS), for estimating health-related functions along eight subscales: physical functioning, role limitations caused by physical problems, bodily pain, general health (components of PCS), role limitations caused by emotional problems, vitality, social functioning, and mental health (components of MCS) [17]. All scores were transformed to a 0–100 scale; 0 indicated the lowest well-being and 100 indicated the highest. The PCS and the MCS were scored at the same time with norm-based methods.

Subjects and procedure

We used a two-stage survey study to approach the firefighters. Because firefighters belong to a special population, we used a population survey instead of random sampling. The office workers that do not have to participate in the firefighting were also excluded. In the first stage, about 557 firefighters in the Kaohsiung city were invited to participate in a health promotion activity that included mental health screening (SF-36, DRPST and questionnaires) and a series of lectures on mental health. They were recruited for mental health screening by voluntarily completing a self-administered questionnaire that focused predominantly on quality of life, psychological problems, psychosocial stressors, and perceived physical problems. All participants gave informed consent to participate in the study after receiving information about the goals and the method of the investigation, together with approval from the local government authorities, and Institute Review Board, Kai-Suan Psychiatric Hospital. A total of 432 firefighters joined this program voluntarily; however, only 412 completed the questionnaire thoroughly and 12 others returned incomplete data. The response rate of effective questionnaires was 94.9% (410/432), and the response rate of the entire sample invited to participate in the study was 77.56% (432/557). In the second stage, psychiatrists classified these probable cases as definite PTSD or major depression according to DSM-IV, and subclinical PTSD or major depression. The results of the questionnaires were mailed to the subjects with assurance that only researchers conducting the study would review their responses. When they were evaluated to have the mental illness or subclinical mental illness, we suggested that they receive psychiatric treatment or self-health management (include changing life style, taking exercise, undergoing cognitive restructuring, joining the relief program or lectures, and learning muscle relaxation techniques, etc.); our mental health managers will regularly call on them to encourage their participation in these health programs.

Data analysis

A comparison of the demographic data (except age) of the firefighters for the three groups was conducted using the chi-square test. Subsequent to summing the Likert-scaled items in the SF-36 survey, each scale was then standardized so that responses ranged from 0 (lowest level of functioning) to 100 (highest level). ANOVA was used to examine the differences in each subscale score of the SF-36 for three groups. We also used a multiple regression model with stepwise analysis to study significant main effect variables and to estimate the magnitude of the effects. To determine which combination of stressors best predicted which individuals would have cases of major depression or PTSD, a χ2 test was performed first to determine which stressors were correlated to major depression or PTSD. Then, we used a logistic regression model with conditional forward analysis to study the significant stressors predictive of major depression or PTSD. All data were analyzed with the SPSS 10.0 statistical analysis software package.

Results

The rates of probable major depression or PTSD among the firefighters, using a cutoff of 2/3 and 4/7 of DRPST, were 9.5% (39/410) and 15.9% (5/410), respectively. The estimated prevalence rates of major depression and PTSD was 5.4% (22/410) and 10.5% (43/410), respectively, according to DSM-IV criteria, and 10 (2.4%) firefighters had PTSD combined with major depression. Others were evaluated as subclinical PTSD (17) or major depression (22). The average age of the 410 firefighters was 36.40 ± 7.13 years. They were all males and 291(71.0%) were married. All respondents had finished their education at the junior high school level or above. Almost firefighters with current PTSD or MD had higher numbers of psychosocial stressors and more perceived physical condition issues than the Health group (See Table 1 in detail).
Table 1

Demographic data in firefighters

 

Health (n = 273)

Subclinical PTSD or MD (n = 82)

Current PTSD or MD (n = 55)

P

n

%

n

%

n

%

 

Age in average

35.03 ± 6.86

41.12 ± 6.58

36.18 ± 6.32

.000

Education level

.002

   Senior high school

104

38.1

48

58.5

29

52.7

 

   College or above

169

61.9

34

41.5

26

47.3

 

Marital status

.224

   Single

82

30.0

15

18.3

13

23.6

 

   Married

184

67.4

66

80.5

41

74.5

 

   Divorced or other

7

2.6

1

1.2

1

1.8

 

Current smoking habit within one year

.055

   Yes

112

41.0

46

56.1

25

45.5

 

   No

161

59.0

36

43.9

30

54.5

 

Current alcohol drinking habit within one year

.076

   Yes

134

49.1

40

48.8

36

65.5

 

   No

139

50.9

42

51.2

19

34.5

 

Financial problem within one year

.000

   Yes

77

28.2

30

36.6

33

60.0

 

   No

196

71.8

52

63.4

22

40.0

 

Marital discord within one year

.000

   Yes

32

11.7

10

12.2

19

34.5

 

   No

241

88.3

72

87.8

36

65.5

 

Family problem within one year

.000

   Yes

17

6.2

8

9.8

14

25.5

 

   No

256

93.8

74

90.2

41

74.5

 

Parenting problem within one year

.005

   Yes

13

4.8

4

4.9

9

16.4

 

   No

260

95.2

78

95.1

46

83.6

 

Criticism due to work performance

.000

   Yes

103

37.7

43

52.4

46

83.6

 

   No

170

62.3

39

47.6

9

16.4

 

Work overload stress

.000

   Yes

116

42.5

44

53.7

45

81.8

 

   No

157

57.5

38

46.3

10

18.2

 

Current cardiovascular system problem

.000

   Yes

31

11.4

13

15.9

19

34.5

 

   No

242

88.6

69

84.1

36

65.5

 

Current sensory system problem

.000

   Yes

58

21.2

29

35.4

31

56.4

 

   No

215

78.8

53

64.6

24

43.6

 

Current respiratory system problem

.001

   Yes

55

20.1

18

22.0

24

43.6

 

   No

218

79.9

64

78.0

31

56.4

 

Current gastrointestinal system problem

.000

   Yes

117

42.9

34

41.5

43

78.2

 

   No

156

57.1

48

58.5

12

21.8

 

Current musculoskeletal system problem

.000

   Yes

125

45.8

47

57.3

46

83.6

 

   No

148

54.2

35

42.7

9

16.4

 

Current Genitourinary system problem

.000

   Yes

27

9.9

9

11.0

25

45.5

 

   No

246

90.1

73

89.0

30

54.5

 

Current skin problem

.000

   Yes

45

16.5

22

26.8

25

45.5

 

   No

228

83.5

60

73.2

30

54.5

 

Sleep disturbance

.000

   Yes

27

9.9

21

25.6

19

34.5

 

   No

246

90.1

61

74.4

36

65.5

 
With PTSD or major depression, the firefighters’ quality of life scored significantly lower than those with subclinical PTSD or major depression and the mental healthy group. This was evident in eight concepts and two domains of the SF-36. Interestingly, there was almost a positive trend in quality of life in firefighters among the following groups: PTSD or MD, subclinical PTSD or MD, and mental health in four physical concepts and PCS. However, firefighters who had psychiatric impairment (PTSD or MD, subclinical PTSD or MD) had poorer quality of life in mental concepts (except ‘vitality’) and MCS. There were no differences in mental concepts and MCS between PTSD or MD and subclinical PTSD or MD (see Table 2 in detail).
Table 2

The comparison of quality of life among firefighters with current PTSD or major depression, subclinical PTSD or major depression and those without PTSD or major depression

 

Health (n = 273)

Subclinical PTSD or MD (n = 82)

Current PTSD or MD (n = 55)

F

Mean

SD

Mean

SD

Mean

SD

 

Physica1 functioninga

94.36

13.08

89.63

16.55

83.45

20.20

13.433

Role limitation caused by Physical problemsa

87.09

28.69

77.13

37.52

52.27

42.02

26.587

Bodily paina

87.34

16.07

80.32

17.87

72.16

18.21

21.173

General healtha

71.71

19.27

65.96

19.62

50.78

15.86

28.445

Vitalitya

67.05

18.03

61.71

17.47

45.27

18.54

33.831

Social functioningb

85.94

14.53

82.16

15.34

64.55

18.91

44.511

Role limitation caused by emotional problemsb

83.03

32.98

76.02

38.23

34.55

42.05

42.996

Mental healthb

70.10

16.22

66.54

15.23

48.95

13.47

41.623

Physical Component Summarya

54.52

6.16

51.74

7.05

49.43

8.47

15.968

Mental Component Summaryb

48.22

8.85

46.45

8.72

34.27

10.60

54.190

aHealth > Subclinical PTSD or MD > Current PTSD or MD

bHealth, Subclinical PTSD or MD > Current PTSD or MD

Table 3 shows the results of multiple regression analyses for prediction of the influence of risk factors on the scores of the quality-of-life subscales. The major predictors of poor quality of life were mental status (major depression, PTSD, and sleep disturbance), psychosocial stressors (especially marital discord, financial problems, family conflict, work overload stress, and criticism due to work performance...etc.) or perceived physical condition (especially current genitourinary and cardiovascular system problems). The results indicated that all eight subscales with two domains were negatively correlated with sleep disturbance, marital discord, and perceived current genitourinary system problems (except the ‘bodily pain’ subscale). Interestingly, most mental subscales (not physical subscales), MCS, and ‘general health’ were negatively correlated with work overload stress. Most physical subscales (except ‘general health’) with PCS were negatively correlated with financial problems. Not surprisingly, mental subscales with MCS were negatively correlated with major depression or sleep disturbance and PTSD; however, there was an interestingly negative correlation between PTSD and ‘role limitation caused by physical problems’ subscale. The adjusted R2 values in the eight subscales and two domains were from .175 to .439.
Table 3

Multiple regressions to predict scores of subscales of SF-36 in 410 firefighters

 

Physical functioning

Role physical

Bodily pain

General health

Vitality

Social functioning

Role emotional

Mental health

Mental component summary

Physical component summary

Age

−0.28**

NS

−0.27*

NS

NS

NS

NS

NS

NS

NS

Married (Y/N)

NS

NS

5.33**

NS

NS

NS

NS

NS

NS

NS

Current alcohol drinking habit within one year (Y/N)

NS

6.53*

NS

NS

NS

NS

NS

−3.44*

NS

NS

Number of past traumatic events

NS

NS

NS

1.23**

0.74*

NS

NS

0.92**

NS

0.37**

Work overload stress within one year (Y/N)

NS

NS

NS

−4.84**

−7.78***

−5.49***

NS

−7.16***

−4.28***

NS

Criticism due to work performance

NS

NS

NS

NS

NS

NS

−11.10**

NS

NS

NS

Family conflict within one year (Y/N)

NS

14.21*

NS

NS

NS

−5.87*

NS

NS

NS

NS

Marital discord within one year (Y/N)

−6.46**

−17.18***

−7.23**

−7.50**

−4.95*

−8.27***

−22.36***

−5.33*

−4.73***

−2.36*

Financial problem within one year (Y/N)

−4.21*

−16.01***

−4.25**

NS

NS

NS

NS

NS

NS

−2.01**

Current major depression

NS

NS

NS

NS

−14.55***

−13.43***

−17.13*

−11.39***

−8.51***

NS

Current PTSD

NS

−10.78*

NS

−5.39*

NS

NS

−14.45**

−6.86**

−3.55**

NS

Sleep disturbance

−9.82***

−8.08*

−8.77***

−7.64***

−9.66***

−12.96***

−14.37**

−7.13***

−4.59***

−3.40***

Current cardiovascular problem (Y/N)

NS

NS

−5.48**

−10.42***

−11.12***

−3.99*

−7.05

−8.38***

−4.68***

NS

Current Genitourinary problem (Y/N)

−5.72**

−19.81***

NS

−8.96***

−4.82*

−4.05*

−15.38**

−4.91*

−3.46**

−2.62**

Current musculoskeletal problem (Y/N)

NS

NS

−10.69***

−5.43**

−4.01*

NS

NS

NS

NS

−3.02***

Current gastrointestinal problem (Y/N)

NS

−7.79*

NS

NS

NS

−3.16*

NS

NS

NS

NS

Current sensory system problem (Y/N)

NS

−9.66**

−3.42*

NS

NS

NS

NS

NS

NS

−1.80*

Current skin problem (Y/N)

NS

NS

NS

NS

NS

NS

−9.58*

NS

NS

NS

Current respiratory problem (Y/N)

NS

NS

NS

−5.14*

NS

NS

−8.53*

NS

NS

NS

Adjusted R2

0.175

0.292

0.399

0.428

0.401

0.413

0.358

0.377

0.439

0.276

P < 0.05, ** P < 0.01, *** P < 0.001, NS: not significant

According to the χ2 test, all divisions of the current physical problems and other psychosocial stressors significantly correlated with major depression or PTSD; however, only current genitourinary (OR: 4.26; 95% CI: 1.96–9.43; OR: 4.98; 95% CI: 1.83–13.57), and ‘criticism due to work performance’ (OR: 3.48; 95% CI: 1.41–8.55; OR: 3.53; 95% CI: 0.95–13.22) were significantly predictive factors of PTSD and MD. The ‘number of past traumatic events’ (OR: 1.31; 95% CI: 1.13–1.52), ‘family conflict within one year’ (OR: 3.51; 95% CI: 1.47–8.36), and current MD (OR: 3.04; 95% CI: 1.05–8.84) were significantly predictive factors of PTSD. ‘Current alcohol drinking habits within one year’ (OR: 4.35; 95% CI: 1.30–14.59), ‘marital discord within one year’ (OR: 2.85; 95% CI: 1.06–7.68), and current PTSD (OR: 3.18; 95% CI: 1.11–9.15) were significantly predictive factors of MD (see Table 4).
Table 4

Regression models for the prediction of PTSD and major depression

 

Current PTSD

Current major depression

Unadjusted coefficient b (SE)

Adjusted coefficient b (SE)

Unadjusted coefficient b (SE)

Adjusted coefficient b (SE)

Current Genitourinary problem

1.812 (0.348)***

1.448 (0.406)***

2.116 (0.455)***

1.606 (0.510)**

Criticism due to work performance

1.940 (0.426)***

1.246 (0.459)**

2.063 (0.630)**

1.262 (0.673)

Current alcohol drinking habit within one year

0.312 (0.326)

NA

1.523 (0.562)**

1.470 (0.617)*

Marital discord within one year

1.133 (0.352)**

NA

1.536 (0.451)**

1.046 (0.506)*

Family conflict within one year

1.737 (0.389)***

1.254 (0.443)**

1.119 (0.539)*

NA

Number of past traumatic events

0.300 (0.066)***

0.268 (0.076)***

0.174 (0.087)*

NA

Current major depression

2.193 (0.465)***

1.113 (0.544)*

NA

Current PTSD

NA

2.193 (0.465)***

1.157 (0.539)*

P < 0.05, ** P < 0.01, *** P < 0.001, NA: not available

Discussion

This study used a quality of life and psychiatric impairments survey of firefighters in the Kaohsiung area to demonstrate the current rate of major depression and PTSD. The lifetime prevalence of PTSD is from 1 to 74% when individuals were exposed to traumatic events [7, 18]. Some studies [8, 19] showed that the prevalence of PTSD in firefighters is higher than that of the general population, but lower than that of disaster survivors. The estimated prevalence (10.5%) of PTSD in our results is within the range of these studies. Although the results of Chang et al. (21.7% PTSD) [8] were two times that of our study, the difference may due to survey timing. The timing of Chang et al.’s survey is post-catastrophic 9/21 earthquake (5 months later), and thus the prevalence of PTSD is higher than ours. However, the higher prevalence of psychiatric diseases highlights the importance of mental health awareness in firefighters.

In the quality-of-life subscales, prominent potential risk factors for poorer quality of life were noted, including demographic data such as age, marital status, psychosocial stressors such as financial problems, work stress within one year...etc., mental illness such as current PTSD, major depression, or sleep disturbance, and perceived physical condition, especially genitourinary or cardiovascular system problems. Although major depression only influenced the mental aspect and not the physical aspect of life quality, PTSD influenced the mostly the mental aspect and only partially the physical aspect of life quality. However, we find the poorest quality of life in firefighters who had PTSD or MD among three groups in eight concepts and two domains without considering other risk factors (Table 2). Interestingly, we found also that sleep disturbance significantly influenced the physical aspect as well as the mental aspect of life quality in firefighters. The results were similar to that of disaster survivors [12, 13]. As we know, insomnia is a criterion of PTSD as well as major depression, so sleep disturbance may be a confounder of PTSD and major depression. Sleep disturbance may directly or indirectly affect an individual’s physical and mental life quality. For example, when an individual had long-term insomnia, his daily executive functions would be affected, and this impairment made his physical aspect of life quality worse. Otherwise, insomnia is a symptom of other psychiatric diseases (such as major depression); when firefighters had sleep disturbances, their mental aspect of life quality was poorer.

Those with perceived physical conditions, especially genitourinary, cardiovascular, and musculoskeletal system problems, showed decreasing scores in most physical aspects of the subscales and some part of the mental aspects, which agrees with our general, intuitive knowledge. Physical illness seemed to affect the quality of life across physical and mental aspects with a predominant effect on the physical [20]. Therefore, mental and physical function should be emphasized simultaneously in any intervention for those with physical illness [3].

The results also provided a profile of stressors correlated with depression and PTSD for the firefighters. As in the results of North et al. [10], we found the rate of alcohol abuse in firefighters is 53.65% (220/410). The resilience seen in firefighters may be related to their career selection. Alcohol disorders were endemic and indicated a need for ongoing programs targeting this problem. Therefore, surveillance for problem drinking may identify useful opportunities for other intervention. Like the policemen in the previous study [3], marital discord and not divorce or separation, was a factor that predicted depression. Divorce or separation is discouraged, and couples―especially those with children―are always encouraged to stay together in Taiwainese culture. Only those with very serious and unresolved problems would divorce or separate, and this might be the only way for them to move to a less stressful life. We also found a predictor of major depression in the job stress aspect was related to ‘criticism due to work performance.’ As we know, the job of firefighters should depend frequently on the fire fighting or disaster rescue work, the victims or officers criticized frequently their work performance due to emergency timing, especially faced on disaster impact. When individuals could not tolerate the input from critics, they got major depression or PTSD. Interestingly, we also found a predictor of major depression as well as PTSD in perceived genitourinary system problems. In Taiwainese culture, the higher the percentage of subjects with psychiatric diseases, the higher percentage of subject felt that their sexual or genitourinary system were dysfunctional. As in many studies [12, 16, 2223], PTSD is a mutual predictor of major depression. The studies had the same results.

Dysfunctional lifestyles, or habits like alcohol abuse, frequently affected quality of life and was a potential risk factor for major depression (OR: 4.35). Some disaster researchers [7, 12, 23] suggested that mental health programs or other preventive strategies might be more effective by specifically targeting subjects rather than by simply targeting a population. As we know, firefighters belong to a high-risk group. We suggested using a screening tool to find suspected cases, and encouraging these subjects to receive further counseling or treatment in mental health programs or preventive strategies. Additionally, when we treat subjects’ psychiatric illness, we should evaluate subjects’ psychosocial stressors according to Hobfoll’s conservation of resources stress theory [15].

This study has some limitations: first, sampling of the firefighters was purposeful; they were recruited from those who had rescue work experience and voluntarily participated in a health promotion activity. Therefore, some of those who participated in our survey might be those who cared about their mental problems or those who had already suffered from emotional illness. Second, we surveyed only work stress and did not emphasize work hazards. Third, we surveyed physical condition by self-reporting, not by actual examination; these factors may have resulted in a subjective bias. Fourth, psychiatrists evaluated them with questionnaires according to DSM-IV; they weren’t evaluated directly by psychiatrists.

Conclusion

The findings from our study could provide fire departments with some information about the relationship among the main stressors, risk of psychiatric illness, and quality of life of their staff. The results suggest that firefighters should be encouraged to receive intervention from mental health professionals. If fire departments could offer mental health services to staff members at risk for major depression or PTSD, the overall performance of the department might improve.

Acknowledgments

The study was supported by grants from the Bureau of Health, Kaohsiung City and from the National Science Council, Republic of China (No. NSC 94-2625-Z-280-001). The authors also appreciated the help from the Fire Bureau, Kaohsiung City.

Copyright information

© Springer Science+Business Media B.V. 2007