Burdens on emergency responders after a terrorist attack in Berlin

Burdens on emergency responders after a terrorist attack in Berlin Abstract Background Terrorist attacks induce various responses in emergency responders. Addressing this range of responses in individual workers is of central interest. Aims To assess the gender- and occupation-specific effects of a terrorist attack, particularly in emergency responders. Methods This was a pilot study. Emergency responders present during the 2016 terrorist attack at Breitscheidplatz in Berlin were asked to participate. Measures for crisis management had been previously implemented. Stress (Patient Health Questionnaire [PHQ]), quality of life (The World Health Organization Quality of Life [WHOQOL-BREF]), post-traumatic stress disorder (PTSD Checklist for DSM-5 [PCL-5]) and current psychological symptoms (Brief Symptom Inventory [BSI]) were assessed. Results Thirty-seven subjects were included, 11 female and 26 male. The occupational groups included 16 firefighters, six police officers, five psychosocial health care personnel and nine members of aid organizations. Three months after the attack, female workers showed higher scores in stress and paranoid ideation, police officers showed higher scores in hostility and firefighters scored lower quality of life in environment and physical health. Conclusions The mental health burden identified in this study plays an important role for emergency responders after terrorist attacks. Differences between occupational groups may be attributable to differences in tasks that responders perform during acute incidents. The presence of these differences 3 months after the incident suggests that these are at least medium-term conditions. This study may inform the development of treatments and policies and it thus recommended to develop a multi-level assessment and treatment programme that is gender- and occupation-specific. Disaster relief, emergency services, mental health, perceived work stressors, women Introduction Terrorist attacks in industrialized nations have increased significantly in the past 20 years, and this trend does not appear to be waning. The psychological consequences of these attacks on both the general population and emergency responders can be even more severe than those of a natural catastrophe [1]. Furthermore, Skogstad and colleagues found that emergency responders show different psychological responses to large-scale attacks, depending on their occupation [2]. While social support, active management of duties and supportive management are helpful in reducing stigma and post-traumatic stress disorder (PTSD) symptoms [3], a wide range of psychological reactions to traumatic events remains to be addressed [4]. However, the various reactions of emergency responders to terrorist attacks in Europe have thus far been the subject of few studies. The objective of this study was to assess the mental health burden among responders from different emergency services and to identify add-ons for the post-incident interventions. Methods All frontline responders and dispatchers involved in the attack who took part in a concluding meeting 3 months after the December 2016 terrorist attack at Breitscheidplatz in Berlin were invited to voluntarily participate in the study after informed consent. Voluntary, routine crisis interventions, which are carried out individually by each organization, had been completed by that time. Participants could complete the questionnaires (including biographic data, occupation and clinical data as described below) either immediately after the meeting or take them home and return them within a week. The participants had the opportunity to voluntarily provide contact data, so that individuals who qualified could be invited to an additional assessment and consultation, as well as treatment if necessary. The study was carried out ethically and was approved by the fire chief and work council of Berlin Fire Department. Post-traumatic stress was assessed using the PTSD Checklist for DSM-5 (PCL-5), a 20-item self-report questionnaire with a rating scale of 0–4. The PCL-5 maps on PTSD symptom clusters of intrusion, avoidance, cognition and mood and hyperarousal, as well as providing a total scale score [5]. Stress was assessed with the Patient Health Questionnaire stress module (PHQ-D). The PHQ-D is a psychodiagnostic questionnaire with 10 items on a rating scale of 0–2 measuring psychosocial stress factors [6]. Quality of life was measured with the brief version of the World Health Organization Quality of Life (WHOQOL-BREF). It contains 26 questions on a five-point Likert scale and is subdivided into four domains: physical health, psychological, social relationships and environment [7]. Current psychological state was measured with the Brief Symptom Inventory (BSI). The BSI contains 53 items on nine primary symptom dimensions: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism [8]. The Wilcoxon rank-sum test for independent samples was used to assess gender-specific differences. The Kruskal-Wallis test was used for comparing different occupational groups. Due to the small sample size in this pilot study, alpha adjustment for multiple comparisons was not conducted. Results Thirty-seven subjects participated, 11 women (30%) and 26 men (70%). The participation rate was 71%. Reasons for non-participation could not be assessed since almost all meeting attendees (92%) took the questionnaires home. Of the respondents, 16 (43%) were firefighters, six (16%) were police officers, six (16%) were members of emergency psychosocial services, and nine (24%) were members of aid organizations. The subjects had a mean age of 42.8 years (SD = 13.2; median = 46 years), and a mean of 13 years of experience working as an emergency responder (SD = 12.8; median = 7 years; range = 41). Details are shown in Table 1. Table 1. Age and service experience of frontline responders and dispatchers participating in the survey   n (%)  AGE  YOS  Mean  SD  Mean  SD  Fire Fighters  Male  14 (38)  45.4  11.3  21.2  12.7  Female  2 (5)  32.5  2.1  7.5  0.7  Total  16 (43)  43.8  11.4  19.5  12.7  AO  Male  7 (19)  37.1  16.6  10.3  14.1  Female  2 (5)  55.5  12.0  7.0  0.0  Total  9 (24)  41.2  17.0  9.9  13.1  Police Officers  Male  4 (11)  36.5  11.0  15.0  14.3  Female  2 (5)  26.0  0.0  1.5  0.7  Total  6 (16)  33.0  10.1  10.5  13.1  EPS  Male  1 3)  -  -  -  -  Female  5 (14)  53.8  4.1  7.0  6.5  Total  6 (16)  -  -  -  -  ALL  Male  26 (70)  41.7  13.1  17.2  13.7  Female  11 (30)  45.2  13.6  6.0  5.0  Overall Total  37 (100)  42.8  13.2  14.0  12.8    n (%)  AGE  YOS  Mean  SD  Mean  SD  Fire Fighters  Male  14 (38)  45.4  11.3  21.2  12.7  Female  2 (5)  32.5  2.1  7.5  0.7  Total  16 (43)  43.8  11.4  19.5  12.7  AO  Male  7 (19)  37.1  16.6  10.3  14.1  Female  2 (5)  55.5  12.0  7.0  0.0  Total  9 (24)  41.2  17.0  9.9  13.1  Police Officers  Male  4 (11)  36.5  11.0  15.0  14.3  Female  2 (5)  26.0  0.0  1.5  0.7  Total  6 (16)  33.0  10.1  10.5  13.1  EPS  Male  1 3)  -  -  -  -  Female  5 (14)  53.8  4.1  7.0  6.5  Total  6 (16)  -  -  -  -  ALL  Male  26 (70)  41.7  13.1  17.2  13.7  Female  11 (30)  45.2  13.6  6.0  5.0  Overall Total  37 (100)  42.8  13.2  14.0  12.8  AO, aid organization; EPS, emergency psychosocial service; SD, standard deviation; YoS, years of service. View Large Pertinent positive findings from the survey instruments are shown in Figure 1. Analysis of survey responses by occupation revealed higher hostility (using the BSI) among police officers (χ2(36,3) = 11.7; P < 0.01), and lower quality of life among firefighters in environment (χ2(36,3) = 11.6; P < 0.01) and physical health (χ2(37,3) = 8.4; P < 0.05). Gender-specific analyses disclosed higher perceived levels of stress from the PHQ-D (Wilcoxon rank-sum ω = 254; P < 0.05) and paranoid ideation scores on the BSI (ω = 260; P < 0.01) among female personnel. Figure 1. View largeDownload slide Kruskal-Wallis test for independent samples showing elevated hostility for police officers and reduced physical and environmental quality of life for firefighters. AO, aid organizations; BSI, Brief Symptom Inventory; EPS, emergency psychosocial services; QOL, quality of life. Figure 1. View largeDownload slide Kruskal-Wallis test for independent samples showing elevated hostility for police officers and reduced physical and environmental quality of life for firefighters. AO, aid organizations; BSI, Brief Symptom Inventory; EPS, emergency psychosocial services; QOL, quality of life. There were no differences between genders and occupational groups in post-traumatic stress symptoms or overall score. Discussion The results suggest that 3 months after the terrorist attack, female emergency responders experienced higher levels of stress and mistrust, police officers had higher scores for hostility, and firefighters showed lower environmental and physical quality of life. The results obtained underline the basis for training measures already planned prior to the study. To our knowledge, this is the first study in Germany investigating the gender- and occupation-specific differences in the self-reported psychological effects of a terrorist attack on responders. However, certain limitations should be considered. Due to the small sample size, alpha adjustment for multiple comparisons was omitted from the analyses, and group differences should be carefully interpreted. Due to the cross-sectional nature of the study, the possibility of previously existing differences between groups cannot be excluded, but a prospective study would not be possible without routine or pre-event assessments. There are no international studies that investigate this topic with measurements taken both before and after a serious incident. The finding that women responders report higher stress after a terrorist attack is consistent with results from previous research, which found that female personnel suffered higher post-traumatic stress than males 10 months after a terrorist attack [2]. While there are no previous studies reporting increased hostility among police officers in the aftermath of a terrorist attack, another study using the BSI (long version: SCL-90-R) found no differences in hostility between police officers and members of other occupational groups, such as firefighters or social welfare employees under normal conditions [9]. The differences in tasks between emergency responders may explain why police officers, whose focus of attention is on perpetrators rather than victims, displayed higher levels of aggression in response to the attack. However, these symptoms could be expected to equalize within a period of 3 months. The finding that firefighters reported impaired physical quality of life after a terrorist attack is also consistent with previous research [10]. Despite its limitations, our study provides evidence for differences in the mental health burden between genders and occupational groups, and confirms some prior international research findings. As a result of the threat to the mental health of emergency responders posed by terrorist attacks, a comprehensive approach—termed the Berlin Post-Incident Intervention Model (BEN)—is under development. Key points Three months after the Berlin terrorist attack, female emergency responders experienced elevated levels of stress and paranoid ideation. Police officers showed elevated levels of hostility, and firefighters had a diminished environmental and physical quality of life. The results are to be regarded as provisional. Conflicts of interest None declared. Acknowledgements We would like to thank Wilfried Gräfling, Head of Berlin Fire Department, and Klaus Kandt, Chief of Police in Berlin, for making this study possible and for supporting our work. References 1. Bromet EJ, Atwoli L, Kawakami Net al.   Post-traumatic stress disorder associated with natural and human-made disasters in the World Mental Health Surveys. Psychol Med  2017; 47: 227– 241. Google Scholar CrossRef Search ADS PubMed  2. Skogstad L, Heir T, Hauff E, Ekeberg Ø. Post-traumatic stress among rescue workers after terror attacks in Norway. Occup Med (Lond)  2016; 66: 528– 535. Google Scholar CrossRef Search ADS PubMed  3. Kelley CL, Britt TW, Adler AB, Bliese PD. Perceived organizational support, posttraumatic stress disorder symptoms, and stigma in soldiers returning from combat. Psychol Serv  2014; 11: 229– 234. Google Scholar CrossRef Search ADS PubMed  4. Wesemann U, Schura R, Kowalski JTet al.   Association of deployment and tobacco dependence among soldiers. Gesundheitswesen  2015; 511: 1– 6. 5. Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP. The PTSD Checklist for DSM-5 (PCL-5) . Boston, MA: National Center for PTSD, 2013. 6. Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med  2002; 64: 258– 266. Google Scholar CrossRef Search ADS PubMed  7. Angermeyer MC, Kilian A, Matschinger H. WHOQOL. World Health Organization Quality of Life . Göttingen: Hogrefe, 2000. 8. Derogatis LR, Melisaratos N. The Brief Symptom Inventory: an introductory report. Psychol Med  1983; 13: 595– 605. Google Scholar CrossRef Search ADS PubMed  9. van der Velden PG, Rademaker AR, Vermetten E, Portengen MA, Yzermans JC, Grievink L. Police officers: a high-risk group for the development of mental health disturbances? A cohort study. BMJ  Open 2013;3. Retrieved from http://bmjopen.bmj.com/content/3/1/e001720 (10 June 2017). 10. Yip J, Zeig-Owens R, Hall CBet al.   Health conditions as mediators of the association between World Trade Center exposure and health-related quality of life in firefighters and EMS workers. J Occup Environ Med  2016; 58: 200– 206. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2017. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Occupational Medicine Oxford University Press

Burdens on emergency responders after a terrorist attack in Berlin

Loading next page...
 
/lp/ou_press/burdens-on-emergency-responders-after-a-terrorist-attack-in-berlin-c57zGX4Wyn
Publisher
Oxford University Press
Copyright
© The Author(s) 2017. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com
ISSN
0962-7480
eISSN
1471-8405
D.O.I.
10.1093/occmed/kqx172
Publisher site
See Article on Publisher Site

Abstract

Abstract Background Terrorist attacks induce various responses in emergency responders. Addressing this range of responses in individual workers is of central interest. Aims To assess the gender- and occupation-specific effects of a terrorist attack, particularly in emergency responders. Methods This was a pilot study. Emergency responders present during the 2016 terrorist attack at Breitscheidplatz in Berlin were asked to participate. Measures for crisis management had been previously implemented. Stress (Patient Health Questionnaire [PHQ]), quality of life (The World Health Organization Quality of Life [WHOQOL-BREF]), post-traumatic stress disorder (PTSD Checklist for DSM-5 [PCL-5]) and current psychological symptoms (Brief Symptom Inventory [BSI]) were assessed. Results Thirty-seven subjects were included, 11 female and 26 male. The occupational groups included 16 firefighters, six police officers, five psychosocial health care personnel and nine members of aid organizations. Three months after the attack, female workers showed higher scores in stress and paranoid ideation, police officers showed higher scores in hostility and firefighters scored lower quality of life in environment and physical health. Conclusions The mental health burden identified in this study plays an important role for emergency responders after terrorist attacks. Differences between occupational groups may be attributable to differences in tasks that responders perform during acute incidents. The presence of these differences 3 months after the incident suggests that these are at least medium-term conditions. This study may inform the development of treatments and policies and it thus recommended to develop a multi-level assessment and treatment programme that is gender- and occupation-specific. Disaster relief, emergency services, mental health, perceived work stressors, women Introduction Terrorist attacks in industrialized nations have increased significantly in the past 20 years, and this trend does not appear to be waning. The psychological consequences of these attacks on both the general population and emergency responders can be even more severe than those of a natural catastrophe [1]. Furthermore, Skogstad and colleagues found that emergency responders show different psychological responses to large-scale attacks, depending on their occupation [2]. While social support, active management of duties and supportive management are helpful in reducing stigma and post-traumatic stress disorder (PTSD) symptoms [3], a wide range of psychological reactions to traumatic events remains to be addressed [4]. However, the various reactions of emergency responders to terrorist attacks in Europe have thus far been the subject of few studies. The objective of this study was to assess the mental health burden among responders from different emergency services and to identify add-ons for the post-incident interventions. Methods All frontline responders and dispatchers involved in the attack who took part in a concluding meeting 3 months after the December 2016 terrorist attack at Breitscheidplatz in Berlin were invited to voluntarily participate in the study after informed consent. Voluntary, routine crisis interventions, which are carried out individually by each organization, had been completed by that time. Participants could complete the questionnaires (including biographic data, occupation and clinical data as described below) either immediately after the meeting or take them home and return them within a week. The participants had the opportunity to voluntarily provide contact data, so that individuals who qualified could be invited to an additional assessment and consultation, as well as treatment if necessary. The study was carried out ethically and was approved by the fire chief and work council of Berlin Fire Department. Post-traumatic stress was assessed using the PTSD Checklist for DSM-5 (PCL-5), a 20-item self-report questionnaire with a rating scale of 0–4. The PCL-5 maps on PTSD symptom clusters of intrusion, avoidance, cognition and mood and hyperarousal, as well as providing a total scale score [5]. Stress was assessed with the Patient Health Questionnaire stress module (PHQ-D). The PHQ-D is a psychodiagnostic questionnaire with 10 items on a rating scale of 0–2 measuring psychosocial stress factors [6]. Quality of life was measured with the brief version of the World Health Organization Quality of Life (WHOQOL-BREF). It contains 26 questions on a five-point Likert scale and is subdivided into four domains: physical health, psychological, social relationships and environment [7]. Current psychological state was measured with the Brief Symptom Inventory (BSI). The BSI contains 53 items on nine primary symptom dimensions: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism [8]. The Wilcoxon rank-sum test for independent samples was used to assess gender-specific differences. The Kruskal-Wallis test was used for comparing different occupational groups. Due to the small sample size in this pilot study, alpha adjustment for multiple comparisons was not conducted. Results Thirty-seven subjects participated, 11 women (30%) and 26 men (70%). The participation rate was 71%. Reasons for non-participation could not be assessed since almost all meeting attendees (92%) took the questionnaires home. Of the respondents, 16 (43%) were firefighters, six (16%) were police officers, six (16%) were members of emergency psychosocial services, and nine (24%) were members of aid organizations. The subjects had a mean age of 42.8 years (SD = 13.2; median = 46 years), and a mean of 13 years of experience working as an emergency responder (SD = 12.8; median = 7 years; range = 41). Details are shown in Table 1. Table 1. Age and service experience of frontline responders and dispatchers participating in the survey   n (%)  AGE  YOS  Mean  SD  Mean  SD  Fire Fighters  Male  14 (38)  45.4  11.3  21.2  12.7  Female  2 (5)  32.5  2.1  7.5  0.7  Total  16 (43)  43.8  11.4  19.5  12.7  AO  Male  7 (19)  37.1  16.6  10.3  14.1  Female  2 (5)  55.5  12.0  7.0  0.0  Total  9 (24)  41.2  17.0  9.9  13.1  Police Officers  Male  4 (11)  36.5  11.0  15.0  14.3  Female  2 (5)  26.0  0.0  1.5  0.7  Total  6 (16)  33.0  10.1  10.5  13.1  EPS  Male  1 3)  -  -  -  -  Female  5 (14)  53.8  4.1  7.0  6.5  Total  6 (16)  -  -  -  -  ALL  Male  26 (70)  41.7  13.1  17.2  13.7  Female  11 (30)  45.2  13.6  6.0  5.0  Overall Total  37 (100)  42.8  13.2  14.0  12.8    n (%)  AGE  YOS  Mean  SD  Mean  SD  Fire Fighters  Male  14 (38)  45.4  11.3  21.2  12.7  Female  2 (5)  32.5  2.1  7.5  0.7  Total  16 (43)  43.8  11.4  19.5  12.7  AO  Male  7 (19)  37.1  16.6  10.3  14.1  Female  2 (5)  55.5  12.0  7.0  0.0  Total  9 (24)  41.2  17.0  9.9  13.1  Police Officers  Male  4 (11)  36.5  11.0  15.0  14.3  Female  2 (5)  26.0  0.0  1.5  0.7  Total  6 (16)  33.0  10.1  10.5  13.1  EPS  Male  1 3)  -  -  -  -  Female  5 (14)  53.8  4.1  7.0  6.5  Total  6 (16)  -  -  -  -  ALL  Male  26 (70)  41.7  13.1  17.2  13.7  Female  11 (30)  45.2  13.6  6.0  5.0  Overall Total  37 (100)  42.8  13.2  14.0  12.8  AO, aid organization; EPS, emergency psychosocial service; SD, standard deviation; YoS, years of service. View Large Pertinent positive findings from the survey instruments are shown in Figure 1. Analysis of survey responses by occupation revealed higher hostility (using the BSI) among police officers (χ2(36,3) = 11.7; P < 0.01), and lower quality of life among firefighters in environment (χ2(36,3) = 11.6; P < 0.01) and physical health (χ2(37,3) = 8.4; P < 0.05). Gender-specific analyses disclosed higher perceived levels of stress from the PHQ-D (Wilcoxon rank-sum ω = 254; P < 0.05) and paranoid ideation scores on the BSI (ω = 260; P < 0.01) among female personnel. Figure 1. View largeDownload slide Kruskal-Wallis test for independent samples showing elevated hostility for police officers and reduced physical and environmental quality of life for firefighters. AO, aid organizations; BSI, Brief Symptom Inventory; EPS, emergency psychosocial services; QOL, quality of life. Figure 1. View largeDownload slide Kruskal-Wallis test for independent samples showing elevated hostility for police officers and reduced physical and environmental quality of life for firefighters. AO, aid organizations; BSI, Brief Symptom Inventory; EPS, emergency psychosocial services; QOL, quality of life. There were no differences between genders and occupational groups in post-traumatic stress symptoms or overall score. Discussion The results suggest that 3 months after the terrorist attack, female emergency responders experienced higher levels of stress and mistrust, police officers had higher scores for hostility, and firefighters showed lower environmental and physical quality of life. The results obtained underline the basis for training measures already planned prior to the study. To our knowledge, this is the first study in Germany investigating the gender- and occupation-specific differences in the self-reported psychological effects of a terrorist attack on responders. However, certain limitations should be considered. Due to the small sample size, alpha adjustment for multiple comparisons was omitted from the analyses, and group differences should be carefully interpreted. Due to the cross-sectional nature of the study, the possibility of previously existing differences between groups cannot be excluded, but a prospective study would not be possible without routine or pre-event assessments. There are no international studies that investigate this topic with measurements taken both before and after a serious incident. The finding that women responders report higher stress after a terrorist attack is consistent with results from previous research, which found that female personnel suffered higher post-traumatic stress than males 10 months after a terrorist attack [2]. While there are no previous studies reporting increased hostility among police officers in the aftermath of a terrorist attack, another study using the BSI (long version: SCL-90-R) found no differences in hostility between police officers and members of other occupational groups, such as firefighters or social welfare employees under normal conditions [9]. The differences in tasks between emergency responders may explain why police officers, whose focus of attention is on perpetrators rather than victims, displayed higher levels of aggression in response to the attack. However, these symptoms could be expected to equalize within a period of 3 months. The finding that firefighters reported impaired physical quality of life after a terrorist attack is also consistent with previous research [10]. Despite its limitations, our study provides evidence for differences in the mental health burden between genders and occupational groups, and confirms some prior international research findings. As a result of the threat to the mental health of emergency responders posed by terrorist attacks, a comprehensive approach—termed the Berlin Post-Incident Intervention Model (BEN)—is under development. Key points Three months after the Berlin terrorist attack, female emergency responders experienced elevated levels of stress and paranoid ideation. Police officers showed elevated levels of hostility, and firefighters had a diminished environmental and physical quality of life. The results are to be regarded as provisional. Conflicts of interest None declared. Acknowledgements We would like to thank Wilfried Gräfling, Head of Berlin Fire Department, and Klaus Kandt, Chief of Police in Berlin, for making this study possible and for supporting our work. References 1. Bromet EJ, Atwoli L, Kawakami Net al.   Post-traumatic stress disorder associated with natural and human-made disasters in the World Mental Health Surveys. Psychol Med  2017; 47: 227– 241. Google Scholar CrossRef Search ADS PubMed  2. Skogstad L, Heir T, Hauff E, Ekeberg Ø. Post-traumatic stress among rescue workers after terror attacks in Norway. Occup Med (Lond)  2016; 66: 528– 535. Google Scholar CrossRef Search ADS PubMed  3. Kelley CL, Britt TW, Adler AB, Bliese PD. Perceived organizational support, posttraumatic stress disorder symptoms, and stigma in soldiers returning from combat. Psychol Serv  2014; 11: 229– 234. Google Scholar CrossRef Search ADS PubMed  4. Wesemann U, Schura R, Kowalski JTet al.   Association of deployment and tobacco dependence among soldiers. Gesundheitswesen  2015; 511: 1– 6. 5. Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP. The PTSD Checklist for DSM-5 (PCL-5) . Boston, MA: National Center for PTSD, 2013. 6. Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med  2002; 64: 258– 266. Google Scholar CrossRef Search ADS PubMed  7. Angermeyer MC, Kilian A, Matschinger H. WHOQOL. World Health Organization Quality of Life . Göttingen: Hogrefe, 2000. 8. Derogatis LR, Melisaratos N. The Brief Symptom Inventory: an introductory report. Psychol Med  1983; 13: 595– 605. Google Scholar CrossRef Search ADS PubMed  9. van der Velden PG, Rademaker AR, Vermetten E, Portengen MA, Yzermans JC, Grievink L. Police officers: a high-risk group for the development of mental health disturbances? A cohort study. BMJ  Open 2013;3. Retrieved from http://bmjopen.bmj.com/content/3/1/e001720 (10 June 2017). 10. Yip J, Zeig-Owens R, Hall CBet al.   Health conditions as mediators of the association between World Trade Center exposure and health-related quality of life in firefighters and EMS workers. J Occup Environ Med  2016; 58: 200– 206. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2017. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Journal

Occupational MedicineOxford University Press

Published: Jan 1, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 12 million articles from more than
10,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Unlimited reading

Read as many articles as you need. Full articles with original layout, charts and figures. Read online, from anywhere.

Stay up to date

Keep up with your field with Personalized Recommendations and Follow Journals to get automatic updates.

Organize your research

It’s easy to organize your research with our built-in tools.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve Freelancer

DeepDyve Pro

Price
FREE
$49/month

$360/year
Save searches from
Google Scholar,
PubMed
Create lists to
organize your research
Export lists, citations
Read DeepDyve articles
Abstract access only
Unlimited access to over
18 million full-text articles
Print
20 pages/month
PDF Discount
20% off