Rethinking Occupational Health for Emergency Responders in Psychiatry

Cognitive dysfunction in a new patient warranted a broad differential diagnosis, according to Craig Katz, MD. Depression and pseudodementia were more common explanations for memory or executive functioning complaints than trauma, though trauma, including posttraumatic stress disorder (PTSD), remained a relevant consideration because it could produce concentration difficulties, distractibility, and forgetfulness. Trauma screening belonged in every new patient evaluation, Katz said, particularly when cognitive decline was the presenting concern. "If it's someone with cognitive decline who you've never met before, you should certainly ask about it."

Evidence guiding acute trauma care remained limited, Katz noted, describing psychological first aid as evidence-informed rather than evidence-based. Benzodiazepines such as lorazepam and diazepam were widely believed to interfere with natural recovery after trauma, a belief Katz attributed more to animal research than to clinical data, and he said research or clinical experience did not substantiate that harm. A systematic review and meta-analysis, however, found that benzodiazepines were ineffective for the treatment and prevention of PTSD and were associated with worse outcomes, including an increased risk of developing PTSD after recent trauma.¹ Cognitive behavioral therapy had more supporting evidence for short-term benefit after acute trauma than pharmacologic approaches, Katz said. A large-scale, double-blind, placebo-controlled trial could clarify optimal care, Katz said, though ethical and logistical barriers complicate acute-trauma research. Despite acknowledging this evidence gap, Katz reported that he prescribed benzodiazepines to acutely traumatized patients, reasoning that the medications lowered hyperarousal. "I think it brings down their level of hyper-alertness and their state of adrenaline, and I think helps perhaps head off bigger problems."

Katz argued for strong occupational mental health programs for responders, citing the prolonged effects of the September 11, 2001, attacks on first responders as a rationale for building services before, not only after, a disaster. He framed the approach as shifting from a purely postincident model to one that also addressed pretraumatic preparation, anticipating future mass-casualty and climate-related events. A rapid overview of systematic reviews on interventions for occupational stress injury in first responders found that resilience training and other prevention strategies showed some positive outcomes.²

Dr Katz is a psychiatrist at the Icahn School of Medicine in New York City.

References

1. Guina J, Rossetter SR, DeRhodes BJ, et al. Benzodiazepines for PTSD: a systematic review and meta-analysis. J Psychiatr Pract. 2015;21(4):281-303.

2. Antony J, Brar R, Khan PA, et al. Interventions for the prevention and management of occupational stress injury in first responders: a rapid overview of reviews. Syst Rev. 2020;9(1):121.