Prevalence of PTSD and common mental disorders amongst ambulance personnel: a systematic review and meta-analysis



There is increasing concern regarding the mental health impact of first responder work, with some reports suggesting ambulance personnel may be at particularly high risk. Through this systematic review and meta-analysis we aimed to determine the prevalence of mental health conditions among ambulance personnel worldwide.


A systematic search and screening process was conducted to identify studies for inclusion in the review. To be eligible, studies had to report original quantitative data on the prevalence of at least one of the following mental health outcome(s) of interest (PTSD, depression, anxiety, general psychological distress) for ambulance personnel samples. Quality of the studies was assessed using a validated methodological rating tool. Random effects modelling was used to estimate pooled prevalence, as well as subgroup analyses and meta-regressions for five variables implicated in heterogeneity.


In total, 941 articles were identified across all sources, with 95 full-text articles screened to confirm eligibility. Of these, 27 studies were included in the systematic review, reporting on a total of 30,878 ambulance personnel. A total of 18 studies provided necessary quantitative information and were retained for entry in the meta-analysis. The results demonstrated estimated prevalence rates of 11% for PTSD, 15% for depression, 15% for anxiety, and 27% for general psychological distress amongst ambulance personnel, with date of data collection a significant influence upon observed heterogeneity.


Ambulance personnel worldwide have a prevalence of PTSD considerably higher than rates seen in the general population, although there is some evidence that rates of PTSD may have decreased over recent decades.

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References marked with an asterisk are those studies included in the meta-analysis

  1. 1.

    Beaton R, Murphy S, Johnson C, Pike K, Corneil W (1998) Exposure to duty-related incident stressors in urban firefighters and paramedics. J Trauma Stress 11(4):821–828

    Article  PubMed  CAS  Google Scholar 

  2. 2.

    McFarlane AC, Bryant RA (2007) Post-traumatic stress disorder in occupational settings: anticipating and managing the risk. Occup Med 57(6):404–410

    Article  Google Scholar 

  3. 3.

    Mitchell KS, Wolf EJ, Bovin MJ, Lee LO, Green JD, Rosen RC, Keane TM, Marx BP (2017) Network models of DSM-5 posttraumatic stress disorder: implications for ICD-11. J Abnorm Psychol 126(3):355

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Bennett P, Williams Y, Page N, Hood K, Woollard M, Vetter N (2005) Associations between organizational and incident factors and emotional distress in emergency ambulance personnel. Br J Clin Psychol 44(2):215–226

    Article  PubMed  Google Scholar 

  5. 5.

    Sterud T, Hem E, Lau B, Ekeberg Ø (2011) A comparison of general and ambulance specific stressors: predictors of job satisfaction and health problems in a nationwide one-year follow-up study of Norwegian ambulance personnel. J Occup Med Toxicol 6(1):10

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Kessler RC, Chiu WT, Demler O, Walters EE (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):617–627

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Karam EG, Friedman MJ, Hill ED, Kessler RC, McLaughlin KA, Petukhova M, Sampson L, Shahly V, Angermeyer MC, Bromet EJ (2014) Cumulative traumas and risk thresholds: 12-month PTSD in the World Mental Health (WMH) surveys. Depression Anxiety 31(2):130–142

    Article  PubMed  Google Scholar 

  8. 8.

    Atwoli L, Stein DJ, Koenen KC, McLaughlin KA (2015) Epidemiology of posttraumatic stress disorder: prevalence, correlates and consequences. Curr Opin Psychiatry 28(4):307

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Berger W, Coutinho ESF, Figueira I, Marques-Portella C, Luz MP, Neylan TC, Marmar CR, Mendlowicz MV (2012) Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers. Soc Psychiatry Psychiatr Epidemiol 47(6):1001–1011

    Article  PubMed  Google Scholar 

  10. 10.

    Alexander DA, 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(1):76–81*

    Article  PubMed  CAS  Google Scholar 

  11. 11.

    Skeffington PM, Rees CS, Mazzucchelli T (2017) Trauma exposure and post-traumatic stress disorder within fire and emergency services in Western Australia. Aust J Psychol 69(1):20–28

    Article  Google Scholar 

  12. 12.

    Harvey SB, Milligan-Saville JS, Paterson HM, Harkness EL, Marsh AM, Dobson M, Kemp R, Bryant RA (2016) The mental health of fire-fighters: An examination of the impact of repeated trauma exposure. Aust N Z J Psychiatry 50(7):649–658

    Article  PubMed  Google Scholar 

  13. 13.

    Health NIo (2014) Quality assessment tool for observational cohort and cross-sectional studies. National Heart, Lung, and Blood Institute. Accessed 5 Nov 2015

  14. 14.

    Maass SW, Roorda C, Berendsen AJ, Verhaak PF, de Bock GH (2015) The prevalence of long-term symptoms of depression and anxiety after breast cancer treatment: a systematic review. Maturitas 82(1):100–108

    Article  PubMed  CAS  Google Scholar 

  15. 15.

    Nyaga VN, Arbyn M, Aerts M (2014) Metaprop: a Stata command to perform meta-analysis of binomial data. Arch Public Health 72(1):39

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Arial M, Wild P, Benoit D, Chouaniere D, Danuser B (2011) Multi-level modeling of aspects associated with poor mental health in a sample of prehospital emergency professionals. Am J Ind Med 54(11):847–857*

    Article  PubMed  Google Scholar 

  17. 17.

    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(2):235–236*

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  18. 18.

    Bentley MA, Crawford JM, Wilkins J, Fernandez AR, Studnek JR (2013) An assessment of depression, anxiety, and stress among nationally certified EMS professionals. Prehosp Emerg Care 17(3):330–338*

    Article  PubMed  Google Scholar 

  19. 19.

    Berger W, Figueira I, Maurat AM, Bucassio EP, Vieira I, Jardim SR, Coutinho ES, 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(4):637–642*

    Article  PubMed  Google Scholar 

  20. 20.

    Clohessy S, Ehlers A (1999) PTSD symptoms, response to intrusive memories and coping in ambulance service workers. Br J Clin Psychol 38(3):251–265*

    Article  PubMed  Google Scholar 

  21. 21.

    Courtney JA, Francis AJP, Paxton SJ (2012) Caring for the carers: fatigue, sleep, and mental health in Australian paramedic shiftworkers. Aust N Z J Org Psychol 3:32–41.*

    Article  Google Scholar 

  22. 22.

    McGilloway S, Gallagher S (2009) Experience of critical incident stress among ambulance service staff and relationship to psychological symptoms. Emerg Ment Health 11(4):235–248*

    Google Scholar 

  23. 23.

    Grevin F (1996) Posttraumatic stress disorder, ego defense mechanisms, and empathy among urban paramedics. Psychol Rep 79(2):483–495*

    Article  PubMed  CAS  Google Scholar 

  24. 24.

    Halpern J, Maunder RG, Schwartz B, Gurevich M (2011) Identifying risk of emotional sequelae after critical incidents. Emerg Med J 28(1):51–56*

    Article  PubMed  Google Scholar 

  25. 25.

    Jonsson A, Segesten K, Mattsson B (2003) Post-traumatic stress among Swedish ambulance personnel. Emerg Med J 20(1):79–84*

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  26. 26.

    Lowery K, Stokes MA (2005) Role of peer support and emotional expression on posttraumatic stress disorder in student paramedics. J Trauma Stress 18(2):171–179*

    Article  PubMed  Google Scholar 

  27. 27.

    Misra M, Greenberg N, Hutchinson C, Brain A, Glozier N (2009) Psychological impact upon London Ambulance Service of the 2005 bombings. Occup Med 59(6):428–433*

    Article  Google Scholar 

  28. 28.

    Nortje C, Roberts CB, Möller AT (2004) Judgement of risk in traumatized and nontraumatized emergency medical service personnel. Psychol Rep 95(3_suppl):1119–1128*

    Article  PubMed  Google Scholar 

  29. 29.

    Pyper Z, Paterson JL (2016) Fatigue and mental health in Australian rural and regional ambulance personnel. Emerg Med Australas 28(1):62–66*

    Article  PubMed  Google Scholar 

  30. 30.

    Sterud T, Hem E, Ekeberg Ø, Lau B (2008) Health problems and help-seeking in a nationwide sample of operational Norwegian ambulance personnel. BMC Public Health 8(1):3*

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Streb M, Häller P, Michael T (2014) PTSD in paramedics: resilience and sense of coherence. Behav Cogn Psychother 42(4):452–463*

    Article  PubMed  Google Scholar 

  32. 32.

    Van Der Ploeg E, Kleber RJ (2003) Acute and chronic job stressors among ambulance personnel: predictors of health symptoms. Occup Environ Med 60(suppl 1):i40–i46*

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. Br Med J 327(7414):557

    Article  Google Scholar 

  34. 34.

    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(9):1385–1394

    Article  PubMed  Google Scholar 

  35. 35.

    Creamer M, Burgess P, McFarlane AC (2001) Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-being. Psychol Med 31(7):1237–1247

    Article  PubMed  CAS  Google Scholar 

  36. 36.

    Michael T, Streb M, Häller P (2016) PTSD in paramedics: Direct versus indirect threats, posttraumatic cognitions, and dealing with intrusions. Int J Cogn Therapy 9(1):57–72

    Article  Google Scholar 

  37. 37.

    World Health Organization (2017) Depression and other common mental disorders: global health estimates. World Health Organization, Geneva

    Google Scholar 

  38. 38.

    Goodwin L, Ben-Zion I, Fear NT, Hotopf M, Stansfeld SA, Wessely S (2013) Are reports of psychological stress higher in occupational studies? A systematic review across occupational and population based studies. PLoS One 8(11):e78693

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  39. 39.

    Varker T, Metcalf O, Forbes D, Chisolm K, Harvey S, Van Hooff M, McFarlane A, Bryant R, Phelps AJ (2018) Research into Australian emergency services personnel mental health and wellbeing: an evidence map. Aust N Z J Psychiatry 52:129–148

    Article  PubMed  Google Scholar 

  40. 40.

    Joyce S, Modini M, Christensen H, Mykletun A, Bryant R, Mitchell PB, Harvey SB (2016) Workplace interventions for common mental disorders: a systematic meta-review. Psychol Med 46(4):683–697

    Article  PubMed  CAS  Google Scholar 

  41. 41.

    Marshall RE, Milligan-Saville JS, Mitchell PB, Bryant RA, Harvey SB (2017) A systematic review of the usefulness of pre-employment and pre-duty screening in predicting mental health outcomes amongst emergency workers. Psychiatry Res 253:129–137

    Article  PubMed  Google Scholar 

  42. 42.

    Wessely S, Bryant RA, Greenberg N, Earnshaw M, Sharpley J, Hughes JH (2008) Does psychoeducation help prevent post traumatic psychological distress? Psychiatry. Interpers Biol Process 71(4):287–302

    Article  Google Scholar 

  43. 43.

    North CS, Tivis L, McMillen JC, Pfefferbaum B, Cox J, Spitznagel EL, Bunch K, Schorr J, Smith EM (2002) Coping, functioning, and adjustment of rescue workers after the Oklahoma City bombing. J Trauma Stress 15(3):171–175

    Article  PubMed  Google Scholar 

  44. 44.

    Prati G, Pietrantoni L (2010) The relation of perceived and received social support to mental health among first responders: a meta-analytic review. J Community Psychol 38(3):403–417

    Article  Google Scholar 

  45. 45.

    Pietrzak RH, Goldstein RB, Southwick SM, Grant BF (2011) Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. J Anxiety Disord 25(3):456–465

    Article  PubMed  Google Scholar 

  46. 46.

    Mykletun A, Harvey SB (2012) Prevention of mental disorders: a new era for workplace mental health. Occup Environ Med 69(12):868–869

    Article  PubMed  Google Scholar 

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The systematic review reported in this study was funded by Ambulance Victoria in collaboration with Phoenix Australia. SBH, JMS, AG and MD are supported by funding from NSW Health and the iCare Foundation. This project also benefited from funding from beyondblue and the Movember Foundation.

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SBH and KP conceptualized the study, KP and JMS undertook search and screening processes, KP completed data extraction, KP and SBH carried out statistical analysis, and wrote subsequent versions of the manuscript. All other authors reviewed and approved the final submission.

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Correspondence to Samuel B. Harvey.

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Petrie, K., Milligan-Saville, J., Gayed, A. et al. Prevalence of PTSD and common mental disorders amongst ambulance personnel: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol 53, 897–909 (2018).

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  • Ambulance personnel
  • Emergency services
  • Paramedic
  • Common mental disorder
  • Meta-analysis
  • Post-traumatic stress disorder
  • Prevalence