Psychological distress and alcohol use among fire fighters

BOXER PA, WILD D. Psychological distress and alcohol use among fire fighters. Scand J Work En viron Health 1993;19:121-5. Few studies have investigated stressors to which fire fighters are sub jected and the potential psychological consequences. One hundred and forty-five fire fighters were studied to enumeratepotential occupational stressors, assess psychological distress and problems with alcohol use, and determine whether a relationship exists between these measures and self-reported stressors. Hearing that children are in a burning building was the highest ranked stressor. According to three self-report instruments, between 33 and 41% of the fire fighters were experiencing signifi cant psychological distress, and 29% had possible or probable problems with alcohol use. These fig ures are significantly higher than would be expected in a typical community or working population. In a logistic regression analysis, no relationship was found between measures of psychological dis tress and alcohol use and the 10most highly ranked work stressors.

Jobs Rated Almanac (I) rank s fire fighters as having the mo st stressful job in the United States. Potential stres sors to which fire fighters are exposed range from threat of bodily harm while fighting fire s to boredom while waiting to be summoned. In addition , occupational health inve stigators are becoming increa singly aware of possible long-t erm health hazards of fire fighting. For example, combustion of synthetic material can produce gases which can potentially cause cancer or liver or kidney toxic ity (2).
Several studies have examined the ph ysiological respon ses of fire fighters to alarms, fire fighting, or near-maximal exercise (3)(4)(5) . Average heart rate s as high as 188 beats per minute have been recorded during fire fighting (3). Studies examining the role of psychological factors in the etiology of elevated heart rate s in response to alarm have yielded conflictin g results (3)(4)(5). Emotional stre ss has been considered a possible factor explaining the unu sually high incidence of ischemic stress tests found in a stud y of fire fighters in Los Angeles, California (6) .
No commo n themes emerge from a review of the few studies which have employed widel y divergent methods to look at the relationship between psycho-  (7) scored above 150 "life change units, " a possible predictor of susceptibility to fut ure illness. Paramedics reported a somewhat high er level of stress than did fire fighters. Petrie & Rotherarrr ' s (8) survey of 106 fire fighter s showed that high self-esteem and high assertiveness were associated with low levels of stress. Clarke & Innes (9), studying Australian fire fighters, found tha t fire fight ers high in "sensation-seeking mot ivation" (needing varied and complex sensations and experience s) showed a stro nger relationsh ip between life events and illness than did those with low sensationseek ing motivation. Bieliauskas (10 ) found no relation ship between stressful life events, cortisol level s, and "psychological defensiveness" in the seeking of medical or psychological aid amon g 80 fire fighters. In the largest published study , Kalimo (II ) found that job satisfaction among 260 Finnish fire fighters wa s high , and the prevalence of psychological symptoms was lower than that of the Finnish population. Markowitz (12) , studying 64 fir e fighters who had fought a large polyvinyl chloride fir e, found high levels of demoralization and emotional di stress 22 months after the incident.
In 1985, the National Institute for Occupational Safety and Health initiated a study of occupational stre ss amon g fire fighters at the requ est of the International Association of Fire Fighters (IAFF). A prelim inary que stionnaire was completed by 41 fire fight ers and fire fighting officers who attended an IAFF symposium in Houston, Texas, in September 1985. In Augu st 1986, the Cincinnati, Ohio, Fire Division and Cincinnati fire fighters Union Local 48 (IAFF) supported a larger study, using a revised 317-item questionnaire tak ing approximately 90 min Scand J Work Environ Health 1993, vo119 , no 2 to complete, among Cincinnati fire fighters . The objectives of this study were to enumerate potential workplace stressors, to assess psychological distress and problems with alcohol use, and to determine whether a relationship exists between the levels of the stressors and measures of psychological distress and alcohol use. At the time of the study, the Cincinnati Fire Department employed 769 fire fighters. After reviewing the statistics of the annual report of the Fire Department, we chose eight fire houses representing a spectrum of level of work activity to join the study. Of the 147 fire fighters in these houses, 145 agreed to participate.

Subjects and methods
A list of 72 potential workplace stressors was developed from the published literature (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13), feedback from the questionnaires completed in Houston, and interviews with 10 Cincinnati fire fighters. These stressors were grouped into 10 categories based on the type of job stress (eg, potential toxic exposures, relationship between workers and supervisors, problems with the work, and family-home interface). The objective measures of work stressors consisted of the number of runs during the previous year and the number of hours fighting fires during the previous year.
As measures of psychological distress and alcohol use, we employed validated instruments which permit comparison with published norms. The Symptom Check List (SCL 90-R) consists of 90 items which include the following nine primary symptom dimensions : somatization , obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism (14). The Global Severity Index (GSI) of the SCL-90-R is a summary measure of symptoms reported and level of distress. The General Health Questionnaire (GHQ), a screening instrument for assessing mental health, has been widely used in epidemiologic studies (15,16). The form utilized in this study, consisting of 12 items, was used in a study of the mental health of office workers in Hong Kong (17). The Center for Epidemiologic Studies Depression Scale (CES-D) was developed by the National Institute of Mental Health to measure depressive symptomatology in the general population (18). The aspects of depression measured include feelings of guilt , worthlessness, helplessness and hopelessness, loss of appetite, sleep disturbance, and psychomotor retardation. The CES-D has been found to have high reliability and validity among a variety of general population samples. The Michigan Alcoholism Screening Test (MAST) is a structured self-administered instrument generally considered to be a reliable tool for screening for alcoholi sm (19,20). Using the hypothesis that the level of work stressors (independent variables) would be predictive of measures of psychological distress and alcohol use (dependent variables), we performed a logistic regression analysis (SAS Version 6.04, Statistical Analysis System, Cary, North Carolina). Potential confounding variables consisted of age, race, level of education, measures of social support, marital status, hours of outside employment, years of employment, and personality and environment "domains" of the Derogatis Stress Profile (DSP) (21,22). The DSP is a multidimensional stress profile, consisting of 77 items . The environment domain measures potential stress-inducing events in the home, work, and health environments, while the personality domain measures personality characteristics of reaction to time-induced pressure, driven behavior, attitude posture (achievement orientation), relaxation potential , and role definition. Because our primary interest was to examine potentially clinically significant levels of psychological distress and alcohol use, scores for the dependent variables were dichotomized according to published recommended guidelines (14,15,18,19). A case was defined as a score of at least 0.56 on the GSI of the SCL-90-R (T score <':63),2 on the GHQ, 21 on the CES-D (moderate to severe depression), or 4 on the MAST (possible or probable problem with alcohol use).

Results
Of the 145 male fire department employees surveyed, 107 (76%) were white. Their mean age was 38.7 (range 21-58) years, and their mean length of employment with the fire department was 13.8 (range 1-34) years. The level of schooling ranged from 9 to 17 years. Only two fire fighters (I %) had less than a high school education, and 68 (48%) had continued their education beyond high school. With regard to marital status, 75% were married , 12% had never married, and 13% were separated or divorced. Most of the employees surveyed performed multiple job activities, the most frequent being fire fighter (77%) and emergency medical technician (69%). Eightyfour (58%) of the fire fighters had additional parttime jobs, averaging 21 h weekly.
The 10 highest ranked work stressors are listed in table I. The highest ranked stressor was "hearing that children are in a burning building ," which received an average score of 2.86 out of a possible 4. The three measures of psychological distress utilized were the GHQ, SCL-90-R, and CES-D . On the GHQ, 56 (39%) of the 145 fire fighters scored two or higher, suggestive of a high level of emotional distress. Scores on the SCL-90-R were compared with norms based on test results of 482 male nonpatients. For the 145 fire fighters surveyed, the average GSI score was 0.58 , a score expected to be exceeded by only 10% of a "normal" population. Fifty-nine (41%) of the 145 fire fighters had a GSI score above what is generally considered the "normal" range (above 90th percentile) . The CES-D scores were compared with A diagnosis of alcohol ism cannot be made by questionnaire alone. Nevert heless, MAST provides a good estimate of the likelihood of current problems with alco hol use. Forty-two (29%) of the 145 fire fighters had scores suggesti ve of possible or probable current problems with alcohol use, as outlined in table 2. Table 3 presents the odds ratios (OR) and associated 95% confidence interva ls for the variables entered into the logisti c regression model. The majority of these statistically significant OR values appear to be small. However, OR values which look relatively low are not trivial if the independent variable is continuous. The most striki ng finding was the indication of an increased risk of emotion al distress for those individ uals involved in stressful worker-supervisor relationships. This result is evide nced by the OR of 7.3 for the "relationship between workers and supervisors" variable in a model with CES-D as the dependent variable and other indepen dent varia bles as specified in the Methods section . As an illustration, an OR of 7.3 in this case indicates that an in-Scand J Work Environ Health 1993. vol 19. no 2  dividual's odds of experiencing depression of at least moderate intensity increases by 7.3 for ever y unit change in the "relationship between workers and supervisors" variable, measured on a scale of O~. Thus, an individua l reporting an "e xtreme ly stressful" relationship with supervisors (score 4) had 29 times the odds of experiencing depression as did an individual reporting that his relationship with supervisors is "not at all stres sful" (score 0). Also significant was the change in OR of 2.5 per unit increase in the "relationship betwee n workers and supervisors" variable in a model with GSI as the depe ndent variable. An increased risk of psychol ogical distress, as measured by the GSI for those individuals experiencing physical stress , was indicated by the change 123 Scand J Work Environ Health 1993. vol 19. no 2 in OR of 3.3 per unit increase in the "physical stress" variable. For the CES-D only, a reduced risk of depression was found for individuals having more years of employment (OR 0.66). For the GSI score only, individuals whose spouse did not work outside the home had a reduced risk of psycholo gical distress (OR 0.45 ) compared with tho se fire fighters who were either not married or whose spouse did work outside the home .

Discussion
Results of this study suggest that over one-third of the fire fighters surveyed were experiencing significant psychological distress. The average CES-D score was 12.96, and 33% of the fire fighters scored 16 or higher, a finding suggesting at least mild depression. For comparison, in a large survey of workmen between the ages of 25-74 years in the United States, 6.5% had scores in this range (18). Men in a community sample (23) had an average CES-D score of 7.90. Men with acute depression had an average score of 37.14, and "recovered depressives" had an average score of 18.58.
On the SCL-90-R, the avera ge GSI score of the fire fighters was 0.58, and the median score was 0.46. Utilizing Derogatis' recommended cut-off of the 90th percentile , we found that 41 % of the fire fighters exhibited high distr ess (GSI> 0.56). Using a less stringent cut-off of one standard deviation above the mean of the normati ve male sample from Derog atis ' validation study of the SCL-90-R (14), Parkinson & Bromet (24) found that 21% of the workers at the Three Mile Island nuclear plant exhibited high distress (average GSI 0.28) two years after the accident that occurred there. Green et al (25) surveyed 117 survivors of the Beverly Hills Supper Club fire in northern Kentucky one year after the disaster. The survivors' average GSI score on the SCL-90-R was 0.70, placing them between the norms for "normals" and "psychiatric outpatients." In a study of 104 New York telephone employ ees self-selected for stress, Carrington (26) found an average GSI score of 0.74. A comparison of study results with two-sample ttests showed that the mean GSI score of the 145 fire fighters in this survey was significantly higher than the normal nonpatient norms (14) [t = 8.86, degree s of freedom (df) = I 117, P = 0.0001) and the scores of the nuclear power plant workers in the study of Parkin son et al (24) (t = 5.58, df= 247, P<O.OOOI ). The mean GSI score of the fire fighters was significantly lower than that of a population self-selected for stress (26) (t = -2.44, df = 247, P = 0.015 ), but not significantly different from the mean score of a group of individuals who had experienced a traumatic incident one year earlier (25) (t = -1.95, df = 260, P = 0.094 ).
Thirty-nine percent of the fire fighters had a score of two or higher on the GHQ, a finding suggestive of a high level of emotional distress. Compar ison with previous studies utilizing the GHQ is difficult , since most of the surveys were not conducted in the United States and the questionn aire employed was usually a more comprehensive vers ion of that used in this study. In a study of office workers in Hong Kong, which utilized the version of the GHQ incorporated into the pre sent study, 25.5% of the male office workers scored two or higher (17).
Twenty-nine percent of the fire fighters surveyed had scores on the MAST suggestive of possibl e or probable current problems with alcohol use. Community studies in the United States have found that approximately 13% of the adult population has suffered from alcohol abuse or dependence at some time in their lives (27). At all ages, men are two to five times more likely to be "he avy drinkers" than women. In the original paper describ ing the MAST (19), of 103 individuals who were chosen to exclude "obvious alcoholics," including 67 white male blue-collar university employees and 36 white males randomly selected from patients visiting a university allergy clinic, 13 (13%) of 103 had scores sugges tive of possible or probable current problem s with alcohol use. Thu s the rate of possible or probable current problems with alcohol use among the fire fighters surveyed was high , particularly since the figure of 29% in this survey does not include fire fighters who had problems with alcohol use in the past, but who were abstinent at the time of the survey .
Healthier peopl e tend to enter the work force and remain employed, while less health y people arc underrepresented in the working population , a phenomenon leading to a potential form of selection bias referred to as the " healthy worker effect" (28). It is conceivable that indiv idual s with higher levels of psychological distress or use of alcohol dropped out of the work force prematurely or were never hired by the fire department; thus the levels of psychological morbidity reported for the fire fighters could potenti ally be deflated in compari son with those of community populations. In the absence of information on the psychological status of candidates who were rejec ted for the fire department and that of former fire fighters who left the departm ent prior to usual retirement age, we cannot determine the extent to which the "healthy worke r effect" may have operated in this study. The reduced risk of depression for individuals having a greater length of emplo yment could have been due to seriously depressed individuals dropping out of the work force, but this hypothesis cannot be tested with the available data.
Given the cross -sectional nature of this study, it is not possible to determine the temporal sequence of relationships found in the regression analysis. The strongest finding of the logistic regression model was an increased risk of psycholo gical distress, as measured by the SCL-90-R and CES-D, among those individuals reporting stressful worker-supervisor relationships. However, a study design utilizing self-reported measures of both stressors and mental health may le ad to overcorrelations between environmental stre ss and health and well-being. Watson & Pennebaker (2 9) have suggested that many stres s-he alth correlations may be spuriously inflated because selfreport measures of both stress and health contain a significant component of "negative affectivity," a measure of subjective di stress . The inherently subjective nature of psychological distress makes it difficult to circumvent this potential problem. Howe ver, future studies of psychological distress in fire fighters might be enhanced by the inclusion of standardized structured psychiatric interviews. The findings of this study would ideally be compared with those of a cohort matched for relevant variables such as age, gender, educational level, and physical work activi ty . Only careful clinical evaluation could determine whether fire fighters e xhibiting high levels of ps ychological di stress on sym p tom checklists suffer from actual diagnosable psychiatric disorders.
Despite these limitations, we feel that it is significant that the fire fighters surveyed scored poorly on all measures of mental health in comparison with the results of other published st ud ies utilizing these instru ments in community or occupational sett ings . The so urce s of work stress which may be contributing to these problems remain uncertain, as no relationship was found between measures of psychological di stress and alcohol use and objectively measured work load, and none of the 10 most highly ranked work stressors entered into the regression model. These findings sugges t that our model may la ck critical occupational stress variables, or that factors other than work stress may be more predictive of psychological di stress in the fire fighters stud ie d .