Mental Health and Suicide in the Fire Service

By: Dr. Gamaliel Baer

Firefighting is the second most stressful job in the US after enlisted military and only by a tiny margin⁽¹⁾. Firefighters risk their own lives and health at work while trying to serve the public. Over the course of a career, firefighters will be exposed to many traumatic incidents, and those exposures can add up over time and cause increased stress.

In 2018, the International Association of Fire Fighters (IAFF) partnered with NBC news to conduct a mental health survey of 7000 firefighters⁽²⁾. The findings revealed that there is a distinct need to address mental health in the fire service. For instance, 95% of respondents stated they experienced critical stress on the job, and 75% of respondents stated they have lingering or unresolved emotional issues because of the job stress. It is also notable that of the 85% of firefighters who reported drinking in the 30 days prior to the survey, about half admitted to binge drinking. Additionally, 19% of respondents reported having suicidal thoughts.

As a fire service, we are still working on increasing awareness of mental health, building out behavioral support systems, and collecting data to track suicides. This article provides an overview of data that we have about fire service suicide, how it compares to general population suicide, the overlap of mental health disorders and suicide, and what is currently being done to address the issues of mental health and suicide in the fire service.

National Suicide Statistics for Firefighters and EMTs

The National Fire Protection Association (NPFA) publishes a free yearly report on firefighter fatality statistics. The most recent three fatality reports are from 2018, 2019, and 2020. Those reports state that suicides for firefighters and EMTs are as follows: 82 for firefighters and 21 for EMTs (2018), 119 for firefighters and 20 for EMTs (2019), and 97 for firefighters and 26 for EMTs (2020). These numbers are significantly higher than the number of firefighters dying on duty from a heart attack, which is the leading cause of on-duty death for firefighters.

Comparing Firefighters and the US General Population Demographics

In order to better understand data on firefighters as a group it is important to know a little bit about the US general population statistics. The NFPA publishes demographics of the US fire service, and the most recent data is from 2019. According to the NFPA, the US fire service demographic data by sex and ethnicity are as follows: 96.7% male and 3.3% female; 78.6% White; 11.6% Hispanic or Latino; 8.5% Black; and 1.3% Asian. In comparison, the US general population demographics are as follows: 49.5% male and 50.5% female; 59.3% White; 18.9% Hispanic or Latino; 13.6% Black; and 6.1% Asian⁽³⁾.

Suicide Statistics for US General Population within the Age Range of Working Firefighters

For the US general population, suicide statistics are made available from the National Institute of Health (NIH)⁽⁴⁾. According to the NIH, suicide is the 12th most common cause of death for all ages, but when you restrict the age range to the closest we can get for working firefighters (15-64 years old), suicide jumps to the 5th most common cause of death (after cancer, heart disease, unintentional injury, and COVID) for the latest data from 2020. Historically, suicide was the 4th leading cause of death in this age range. This demonstrates that for the 15-64 age group of the US general population, suicide is a top cause of death.

Suicide Statistics for US General Population by Demographics

The NIH also publishes data on suicide rates by demographics. The way the NIH provides suicide data is per 100,000 individuals. Males have an average suicide rate of 22 per 100,000 and females have an average suicide rate of 5.5 per 100,000. Across all ages, the suicide rates for different ethnicities are as follows from highest to lowest: American Indian (37.4); White (27); Black (12.9); Hispanic (12.3); and Asian (10.3). The average for the entire US general population is 13.5 per 100,000. Although American Indians (AI) have the highest rate of suicide, they make up a tiny fraction of the total US population. The highest impact groups for suicide in the US are the White population and the male population.

Comparing Firefighter Statistics to US General Population Statistics

78.6% of career firefighters are White vs 59.3% of the US general population, and 96.7% of career firefighters are male while 49.5% of the US general population is male. White males are the biggest impact group for suicide. Therefore, any discussion about suicide for the fire service (which is mostly White and male), needs to take into consideration that the fire service currently happens to be a good representation of the biggest impact group for suicide in the US general population.

The White suicide rate is double the rate of the US average suicide rate (27 compared to 13.5 respectively). Black, Hispanic, and Asian males, and all female ethnic groups, all have lower suicide rates than the US average rate. Furthermore, the fire service is almost entirely male (96.7%). According to the National Institute of Health, males die by suicide at a rate 4 times higher than females. Therefore, when considering that the fire service is mostly White male, the suicide rate should be expected to be higher for firefighters as a group than for the general public, even before you take the stress of firefighting into account. Interestingly, a 2018 White Paper by the Ruderman Foundation⁽⁵⁾ used Firefighter Behavioral Health Alliance (FBHA) data to estimate that the firefighter suicide rate is 18 per 100,000 and at the time the general population was 13 per 100,000. If this is accurate, can the higher rate be attributed to demographics alone?

CDC Suicide Data vs Psychological Autopsies and Why That Matters

Up until about 2018 or 2019, if you were to search the internet for the percentage of people that had diagnosable mental health disorders who died by suicide, you would have found a common number everywhere. That number was 90%. At some point, that number completely disappeared from the web and is almost impossible to find now.

The 90% number comes from research studies^(6,7) that involved what are called psychological autopsies, where investigators review medical records, and interview family members, among other methods, to understand the status of the individual’s mental health.

If you were to go to the CDC suicide website⁽⁸⁾ you would find a completely different number. One of the first numbers you see on the CDC’s website is that 54% of people who died by suicide did not have a known mental health condition. It may be the case that the CDC is trying to reduce stigma about mental health disorders, and reducing stigma is a noble goal. However, it appears that the CDC is providing their numbers off of very skimpy data.

If you continue looking on the CDC website, you will find a graphic that explains that there are many factors that contribute to suicide, other than mental health problems. The graphic includes examples such as financial problems, problematic substance use, and relationship problems. Interestingly, the Diagnostic and Statistical Manual (DSM) which is used by psychologists and mental health professionals to diagnose mental health disorders, has a section on substance use disorders. So right off the bat, if you take the 45% of known mental health disorders for suicide victims and add 28% of suicide victims who had known substance abuse disorders, you get 73% of suicide victims that have a diagnosable mental health disorder.

The CDC confesses, in very tiny print, that the only sources of their information for mental health disorders come from coroner’s reports and police reports, and nothing else. Even if the coroner and police officer who wrote the report knew the victim, those two pieces of data fall far short of a psychological autopsy. Therefore, it must be understood that even if the 90% number is to be challenged, the CDC’s number of 45% does not pass the sniff test, and leaves out problematic substance abuse which if included brings the number to at least 73%. Whether you believe the number is closer to 73% or to 90%, the point to understand is that a large portion of people who die by suicide are struggling with some sort of diagnosable, and therefore treatable, mental health disorder.

A Call for Action

The National Fallen Firefighters Foundation (NFFF) is a non-profit organization that was founded by Congress in 1992 with a mission to honor the fallen firefighters in the US, to support their loved ones, but also to educate the fire service in order to prevent more line of duty deaths. In 2004, the NFFF published their 16 Firefighter Life Safety Initiatives⁽⁹⁾. The 13th initiative is called Psychological Support, and it cites NFPA 1500 and calls for departments to provide behavioral health support for firefighters, EMS professionals, and their families. Things are improving, but they take time.

In 2021, the NFPA published its 5th Needs Assessment of the US Fire Service⁽¹⁰⁾. The report found that 73% of fire departments lack behavioral health programs. The problem appears to be more significant as the size of the department gets smaller. Of the departments that did have a behavioral health program, 90% reported having PTSD support services. However, the number of departments that offered preventive education related to behavioral health was significantly lower. Only 50% of fire departments that had a behavioral health program provided education on suicide. There were even fewer departments that offered education on wellness, behavioral health, and physical health (which are all features of NFPA 1500 and 1583).

As firefighters, we know how important learning is, because we understand that “we don’t know what we don’t know”. When it comes to mental health and suicide, education is a key component of prevention. If your department does not have a behavioral health program or preventive education, consider contacting the NFFF (https://www.everyonegoeshome.com/contact/) to see what options are available for free in order to get your department started in the right direction.

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