Social Psychiatry and Psychiatric Epidemiology

, Volume 47, Issue 6, pp 1001–1011 | Cite as

Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers

  • William BergerEmail author
  • Evandro Silva Freire Coutinho
  • Ivan Figueira
  • Carla Marques-Portella
  • Mariana Pires Luz
  • Thomas C. Neylan
  • Charles R. Marmar
  • Mauro Vitor Mendlowicz
Original Paper



We sought to estimate the pooled current prevalence of posttraumatic stress disorder (PTSD) among rescue workers and to determine the variables implicated in the heterogeneity observed among the prevalences of individual studies.


A systematic review covering studies reporting on the PTSD prevalence in rescue teams was conducted following four sequential steps: (1) research in specialized online databases, (2) review of abstracts and selection of studies, (3) review of reference list, and (4) contact with authors and experts. Prevalence data from all studies were pooled using random effects model. Multivariate meta-regression models were fitted to identify variables related to the prevalences heterogeneity.


A total of 28 studies, reporting on 40 samples with 20,424 rescuers, were selected. The worldwide pooled current prevalence was 10%. Meta-regression modeling in studies carried out in the Asian continent had, on average, higher estimated prevalences than those from Europe, but not higher than the North American estimates. Studies of ambulance personnel also showed higher estimated PTSD prevalence than studies with firefighters and police officers.


Rescue workers in general have a pooled current prevalence of PTSD that is much higher than that of the general population. Ambulance personnel and rescuers from Asia may be more susceptible to PTSD. These results indicate the need for improving pre-employment strategies to select the most resilient individuals for rescue work, to implement continuous preventive measures for personnel, and to promote educational campaigns about PTSD and its therapeutic possibilities.


Posttraumatic stress disorder Prevalence Rescue workers Disaster Meta-analysis 



This work was supported by CNPq (Nacional Research Council)—Federal Government of Brazil, FAPERJ—Programa de Apoio às Instituições de Ensino e Pesquisa (Projeto E-6/110.324/2007), and Confederação Nacional do Comércio de Bens, Serviços e Turismo (CNC). Drs. Berger, Coutinho, Figueira and Mendlowicz were partially supported by grants from CNPq. Dr. Marmar was partially supported by grant R01-MH056350-06 from the National Institute of Mental Health. Dr. Neylan was partially supported by the NIMH grants: MH057157 and MH73978.


  1. 1.
    Marmar CR, McCaslin SE, Metzler TJ, Best S, Weiss DS, Fagan J, Liberman A, Pole N, Otte C, Yehuda R, Mohr D, Neylan T (2006) Predictors of posttraumatic stress in police and other first responders. Blackwell, Oxford, pp 1–18Google Scholar
  2. 2.
    Norris FH (1992) Epidemiology of trauma: frequency and impact of different potentially traumatic events on different demographic groups. J Consult Clin Psychol 60:409–418PubMedCrossRefGoogle Scholar
  3. 3.
    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edn. Revised. American Psychiatric Press, WashingtonGoogle Scholar
  4. 4.
    Neuner F, Schauer M, Karunakara U, Klaschik C, Robert C, Elbert T (2004) Psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder trough previous trauma among West Nile refugees. BMC Psychiatry 4:34Google Scholar
  5. 5.
    American Psychiatric Association (1980) Diagnostic and statistical manual of mental disorders, 3th edn. American Psychiatric Press, WashintonGoogle Scholar
  6. 6.
    Morren M, Yzermans CJ, van Nispen RMA, Wevers SJM (2005) The health of volunteer firefighters three years after a technological disaster. J Occup Health 47:523–532PubMedCrossRefGoogle Scholar
  7. 7.
    Stewart SH, Mitchell TL, Wright KD, Loba P (2004) The relations of PTSD symptoms to alcohol use and coping drinking in volunteers who responded to the Swissair Flight 111 airline disaster. J Anxiety Disord 18:51–68PubMedCrossRefGoogle Scholar
  8. 8.
    Perrin MA, DiGrande L, Wheeler K, Thorpe L, Farfel M, Brackbill R (2007) Differences in PTSD prevalence and associated risk factors among world trade center disaster rescue and recovery workers. Am J Psychiatry 164:1385–1394PubMedCrossRefGoogle Scholar
  9. 9.
    Fullerton CS, Ursano RJ, Wang LM (2004) Acute stress disorder, posttraumatic stress disorder, and depression in disaster or rescue workers. Am J Psychiatry 161:1370–1376PubMedCrossRefGoogle Scholar
  10. 10.
    Berger W, Figueira I, Maurat AM, Bucassio EP, Vieira I, Jardirn SR, Coutinho ESE, Mari JJ, Mendlowicz MV (2007) Partial and full PTSD in Brazilian ambulance workers: prevalence and impact on health and on quality of life. J Trauma Stress 20:637–642PubMedCrossRefGoogle Scholar
  11. 11.
    Alvarez J, Hunt M (2005) Risk and resilience in canine search and rescue handlers after 9/11. J Trauma Stress 18:497–505PubMedCrossRefGoogle Scholar
  12. 12.
    Wagner D, Heinrichs M, Ehlert U (1998) Prevalence of symptoms of posttraumatic stress disorder in German professional firefighters. Am J Psychiatry 155:1727–1732PubMedGoogle Scholar
  13. 13.
    DiMaggio C, Galea S (2006) The behavioral consequences of terrorism: a meta-analysis. Acad Emerg Med 13:559–566PubMedCrossRefGoogle Scholar
  14. 14.
    Ward CL, Lombard CJ, Gwebushe N (2006) Critical incident exposure in South African emergency services personnel: prevalence and associated mental health issues. Emerg Med J 23:226–231PubMedCrossRefGoogle Scholar
  15. 15.
    Horowitz M, Wilner N, Alvarez W (1979) Impact of Event Scale: a measure of subjective stress. Psychosom Med 41:209–218PubMedGoogle Scholar
  16. 16.
    Alexander DAF, Klein S (2001) Ambulance personnel and critical incidents: impact of accident and emergency work on mental health and emotional well-being. Br J Psychiatry 178:76–81PubMedCrossRefGoogle Scholar
  17. 17.
    Bryant RA, Harvey AG (1996) Posttraumatic stress reactions in volunteer firefighters. J Trauma Stress 9:51–62PubMedCrossRefGoogle Scholar
  18. 18.
    Corneil W, Beaton RD, Murphy SA, Johnson C, Pike K (1999) Exposure to traumatic incidents and prevalence of posttraumatic stress symptomatology in urban firefighters in two countries. J Occup Health Psychol 4:131–141PubMedCrossRefGoogle Scholar
  19. 19.
    Ersland S, Weisaeth L, Sund A (1989) The stress upon rescuers involved in an oil rig disaster: “Alexander L. Kielland” 1980. Acta Psychiatr Scand Suppl 355:38–49PubMedCrossRefGoogle Scholar
  20. 20.
    Grieger TA, Staab JP, Cardena E, McCarroll JE, Brandt GT, Fullerton CS, Ursano RI (2000) Acute stress disorder and subsequent posttraumatic stress disorder in a group of exposed disaster workers. Depress Anxiety 11:183–184PubMedCrossRefGoogle Scholar
  21. 21.
    Jonsson A, Segesten K (2004) Daily stress and concept of self in Swedish ambulance personnel. Prehosp Disaster Med 19:226–234PubMedGoogle Scholar
  22. 22.
    van der Ploeg E, Kleber RJ (2003) Acute and chronic job stressors among ambulance personnel: predictors of health symptoms. Occup Environ Med 60:i40–i46PubMedCrossRefGoogle Scholar
  23. 23.
    Goldberg DP, Williams P (1988) A user’s guide to the General Health Questionnarie. NFER-Nelson, WindsorGoogle Scholar
  24. 24.
    McFarlane AC (1986) Long-term psychiatric morbidity after a natural disaster: implications for disaster planners and emergency services. Med J Aust 145:561–563PubMedGoogle Scholar
  25. 25.
    Goldberg DP, Blackwel B (1970) Psychiatric illness in general practice—a detailed study using a new method of case identification. Br Med J 2:439–443CrossRefGoogle Scholar
  26. 26.
    Salama-Younes M, Montazeri A, Ismail A, Roncin C (2009) Factor structure and internal consistency of the 12-item General Health Questionnaire (GHQ-12) and the Subjective Vitality Scale (VS), and the relationship between them: a study from France. Health Qual Life Outcomes 7:22PubMedCrossRefGoogle Scholar
  27. 27.
    Wu KK, Chan KS (2003) The development of the Chinese version of Impact of Event Scale—revised (CIES-R). Soc Psychiatry Psychiatr Epidemiol 38:94–98PubMedCrossRefGoogle Scholar
  28. 28.
    Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB, Meta-analysis Of Observational Studies in Epidemiology Group (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. JAMA 283:2008–2012PubMedCrossRefGoogle Scholar
  29. 29.
    International Monetary Fund. World Economic Outlook Database—WEO Groups and Aggregates Information. 2008
  30. 30.
    Borenstein M, Hedges LV, Higgins JPT, Rothstein HR (2009) Introduction to meta-analysis. Wiley, West SussexCrossRefGoogle Scholar
  31. 31.
    Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558PubMedCrossRefGoogle Scholar
  32. 32.
    Hosmer DW, Lemeshow S (2000) Applied logistic regression. Wiley, New YorkCrossRefGoogle Scholar
  33. 33.
    Sims A, Sims D (1998) The phenomenology of post-traumatic stress disorder: a symptomatic study of 70 victims of psychological trauma. Psychopathology 31:96–112PubMedCrossRefGoogle Scholar
  34. 34.
    Andrews L, Joseph S, Shevlin M, Troop N (2006) Confirmatory factor analysis of posttraumatic stress symptoms in emergency personnel: an examination of seven alternative models. Personal Individ Differ 41:213–224CrossRefGoogle Scholar
  35. 35.
    Bennett P, Williams Y, Page N, Hood K, Woollard M (2004) Levels of mental health problems among UK emergency ambulance workers. Emerg Med J 21:235–236PubMedCrossRefGoogle Scholar
  36. 36.
    Bryant RA, Sutherland K, Guthrie RM (2007) Impaired specific autobiographical memory as a risk factor for posttraumatic stress after trauma. J Abnorm Psychol 116:837–841PubMedCrossRefGoogle Scholar
  37. 37.
    Chen YS, Chen MC, Chou FHC, Sun FC, Chen PC, Tsai KY, Chao SS (2007) The relationship between quality of life and posttraumatic stress disorder or major depression for firefighters in Kaohsiung, Taiwan. Qual Life Res 16:1289–1297PubMedCrossRefGoogle Scholar
  38. 38.
    Clohessy S, Ehlers A (1999) PTSD symptoms, response to intrusive memories and coping in ambulance service workers. Br J Clin Psychol 38:251–265PubMedCrossRefGoogle Scholar
  39. 39.
    Dean PG, Gow KM, Shakespeare-Finch J (2003) Counting the cost: psychological distress in career and auxiliary firefighters. Australas J Disaster Trauma Stud 1:1–13Google Scholar
  40. 40.
    Del Ben KS, Scotti JR, Chen YC, Fortson BL (2006) Prevalence of posttraumatic stress disorder symptoms in firefighters. Work Stress 20:37–48CrossRefGoogle Scholar
  41. 41.
    Di Fiorino M, Massimetti G, Nencioni M, Paoli RA (2004) Full and subthreshold Post-Traumatic Stress Disorder seven years after a flooding in rescue squads. Bridging East West Psychiatry 2:18–25Google Scholar
  42. 42.
    Dudek B, Koniarek J (2000) Relationship between sense of coherence and post-traumatic stress disorder symptoms among firefighters. Int J Occup Med Environ Health 13:299–305PubMedGoogle Scholar
  43. 43.
    Durham TW, McCammon SL, Allison EJ (1985) The psychological impact of disaster on rescue personnel. Ann Emerg Med 14:664–668PubMedCrossRefGoogle Scholar
  44. 44.
    Gabriel R, Ferrando L, Corton ES, Mingote C, Garcia-Camba E, Liria AF, Galea S (2007) Psychopathological consequences after a terrorist attack: an epidemiological study among victims, the general population, and police officers. Eur Psychiatry 22:339–346PubMedCrossRefGoogle Scholar
  45. 45.
    Grevin F (1996) Posttraumatic stress disorder, ego defense mechanisms, and empathy among urban paramedics. Psychol Rep 79:483–495PubMedCrossRefGoogle Scholar
  46. 46.
    Guo YJ, Chen CH, Lu ML, Tan HKL, Lee HW, Wang TN (2004) Posttraumatic stress disorder among professional and nonprofessional rescuers involved in an earthquake in Taiwan. Psychiatry Res 127:35–41PubMedCrossRefGoogle Scholar
  47. 47.
    Guthrie RM, Bryant RA (2006) Extinction learning before trauma and subsequent posttraumatic stress. Psychosomat Med 68:307–311CrossRefGoogle Scholar
  48. 48.
    Hagh-Shenas H, Goodarzi MA, Dehbozorgi G, Farashbandi H (2005) Psychological consequences of the bam earthquake on professional and nonprofessional helpers. J Trauma Stress 18:477–483PubMedCrossRefGoogle Scholar
  49. 49.
    Haslam C, Mallon K (2003) A preliminary investigation of post-traumatic stress symptoms among firefighters. Work Stress 17:277–285CrossRefGoogle Scholar
  50. 50.
    Heinrichs M, Wagner D, Schoch W, Soravia LM, Hellhammer DH, Ehlert U (2005) Predicting posttraumatic stress symptoms from pretraumatic risk factors: a 2-year prospective follow-up study in firefighters. Am J Psychiatry 162:2276–2286PubMedCrossRefGoogle Scholar
  51. 51.
    Huizink AC, Slottje P, Witteveen AB, Bijlsma JA, Twisk JWR, Smidt N, Bramsen I, van Mechelen W, Van Der Ploeg HM, Bouter LM, Smid T (2006) Long term health complaints following the Amsterdam Air Disaster in police officers and fire-fighters. Occup Environ Med 63:657–662PubMedCrossRefGoogle Scholar
  52. 52.
    Lowery K, Stokes MA (2005) Role of peer support and emotional expression on posttraumatic stress disorder in student paramedics. J Trauma Stress 18:171–179PubMedCrossRefGoogle Scholar
  53. 53.
    Ozen S, Sir A (2004) Frequency of PTSD in a group of search, rescue workers two months after 2003 Bingol (Turkey) earthquake. J Nerv Ment Dis 192:573–575PubMedCrossRefGoogle Scholar
  54. 54.
    Renck B, Weisaeth L, Skarbo S (2002) Stress reactions in police officers after a disaster rescue operation. Nord J Psychiatry 56:7–14PubMedCrossRefGoogle Scholar
  55. 55.
    Seedat S, La Grange H, Niehaus D, Stein DJ (2003) Stress and resilience in South African firefighters. S Afr Med J 93:236–238PubMedGoogle Scholar
  56. 56.
    Weiss DS, Marmar CR, Metzler TJ, Ronfeldt HM (1995) Predicting symptomatic distress in emergency services personnel. J Consult Clin Psychol 63:361–368PubMedCrossRefGoogle Scholar
  57. 57.
    Long ME, Meyer DL, Jacobs GA (2007) Psychological distress among American Red Cross disaster workers responding to the terrorist attacks of September 11, 2001. Psychiatry Res 149:303–308PubMedCrossRefGoogle Scholar
  58. 58.
    Creamer M, Burgees P, McFarlane AC (2001) Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-being. Psychol Med 3:1237–1247Google Scholar
  59. 59.
    de Vries GJ, Olff M (2009) The lifetime prevalence of traumatic events and posttraumatic stress disorder in the Netherlands. J Trauma Stress 22:259–267PubMedCrossRefGoogle Scholar
  60. 60.
    Eun HJ, Lee SM, Kim TH (2001) The epidemiological study of posttraumatic stress disorder in an urban area. J Korean Neuropsychiatr Assoc 40:581–591Google Scholar
  61. 61.
    Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62:617–627PubMedCrossRefGoogle Scholar
  62. 62.
    Richardson LK, Frueh BC, Acierno R (2010) Prevalence estimates of combat-related post-traumatic stress disorder: critical review. Aust N Z J Psychiatry 44:4–19PubMedCrossRefGoogle Scholar
  63. 63.
    Thompson WW, Gottesman II, Zalewski C (2006) Reconciling disparate prevalence rates of PTSD in large samples of US male Vietnam veterans and their controls. BMC Psychiatry 6:19PubMedCrossRefGoogle Scholar
  64. 64.
    Galea S, Nandi A, Vlahov D (2005) The epidemiology of post-traumatic stress disorder after disasters. Epidemiol Rev 27:78–91PubMedCrossRefGoogle Scholar
  65. 65.
    North CS, Tivis L, McMillen JC, Pfefferbaum B, Cox J, Spitznagel EL, Bunch KP, Schorr J, Smith EM (2002) Coping, functioning, and adjustment of rescue workers after the Oklahoma City bombing. J Trauma Stress 15:171–175PubMedCrossRefGoogle Scholar
  66. 66.
    Marmar CR, Weiss DS, Metzler TJ, Ronfeldt HM, Foreman C (1996) Stress responses of emergency services personnel to the Loma Prieta earthquake Interstate 880 freeway collapse and control traumatic incidents. J Trauma Stress 9:63–85PubMedCrossRefGoogle Scholar
  67. 67.
    Young KM, Cooper CL (1995) Occupational stress in the ambulance service: a diagnostic study. J Manag Psychol 10:29–36CrossRefGoogle Scholar
  68. 68.
    Jonsson A, Segesten K (2004) Guilt, shame and need for a container: a study of post-traumatic stress among ambulance personnel. Accid Emerg Nurs 12:215–223PubMedCrossRefGoogle Scholar
  69. 69.
    Shafique M, Van Der Meijde A, Kerle N, Van Der Meer F, Khan MA (2008) Predicting topographic aggravation of seismic ground shaking by applying geospatial tools. J Himal Earth Sci 41:33–43Google Scholar
  70. 70.
    Udomratn P (2008) Mental health and the psychosocial consequences of natural disasters in Asia. Int Rev Psychiatry 20:441–444PubMedCrossRefGoogle Scholar
  71. 71.
    Tolin DF, Foa EB (2006) Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research. Psychol Bull 132:959–992PubMedCrossRefGoogle Scholar
  72. 72.
    Lilly MM, Pole N, Best SR, Metzler T, Marmar CR (2009) Gender and PTSD: what can we learn from female police officers? J Anxiety Disord 23:767–774PubMedCrossRefGoogle Scholar
  73. 73.
    Koopman C, Hermanson K, Diamond S, Angell K, Spiegel D (1998) Social support, life stress, pain and emotional adjustment to advanced breast cancer. Psychooncology 7:101–111PubMedCrossRefGoogle Scholar
  74. 74.
    Feldner MT, Monson CM, Friedman MJ (2007) A critical analysis of approaches to targeted PTSD prevention: current status and theoretically derived future directions. Behav Modif 31:80–116PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • William Berger
    • 1
    • 2
    • 3
    Email author
  • Evandro Silva Freire Coutinho
    • 4
  • Ivan Figueira
    • 1
  • Carla Marques-Portella
    • 1
  • Mariana Pires Luz
    • 1
  • Thomas C. Neylan
    • 2
    • 3
  • Charles R. Marmar
    • 2
    • 3
  • Mauro Vitor Mendlowicz
    • 1
    • 5
  1. 1.Institute of PsychiatryUniversidade Federal do Rio de Janeiro (IPUB-UFRJ)Rio de JaneiroBrazil
  2. 2.Department of PsychiatryUniversity of California, San Francisco (UCSF)San FranciscoUSA
  3. 3.San Francisco Department of Veterans Affairs Medical Center (DVAMC)Psychiatry ServiceSan FranciscoUSA
  4. 4.Department of EpidemiologyEscola Nacional de Saúde Pública (ENSP-FIOCRUZ)Rio de JaneiroBrazil
  5. 5.Department of Psychiatry and Mental HealthUniversidade Federal Fluminense (MSM-UFF)NiteróiBrazil

Personalised recommendations