A systematic review of the usefulness of pre-employment and pre-duty screening in predicting mental health outcomes amongst emergency workers
Introduction
Mental disorders are now the leading cause of sickness absence in most developed countries (Black, 2008, Cattrell et al., 2011, Harvey et al., 2009, Murray et al., 2012). The impact is particularly great amongst a number of high-risk occupations, such as emergency service workers, where repeated exposure to destressing or traumatic incidents can have a range of adverse mental health outcomes.(Harvey et al., 2015) Recent estimates suggest that up to 10% of first response emergency workers may be suffering from post-traumatic stress disorder (PTSD) (Berger et al., 2012), with similar numbers reporting other trauma-related mental health disorders, such as depression. While such figures highlight the increased risk associated with emergency service work, they also demonstrate that even amongst this trauma-exposed group only a minority will develop PTSD or other long-term mental health problems (Bryant and Guthrie, 2007). This raises the question of whether it is possible to predict which individuals will be resilient to the cumulative trauma exposure that occurs with emergency service work. Pre-employment screening is carried out by many emergency services in the hope of identifying pre-morbid predictors for mental health disorder in order to reduce the cost of absenteeism, but there remains surprisingly little evidence regarding its effectiveness or any useful information to guide this process.
Epidemiological research with the general population (Kessler et al., 1995), and studies of other high-risk groups such as disaster victims (Shore et al., 1986), Vietnam veterans (Green et al., 1990), and victims of crime (Resnick et al., 1993), have shown that predisposing factors for PTSD can be reliably identified. Risk factors identified from prospective studies in other groups include existing psychopathology, childhood trauma, personality characteristics such as introversion and neuroticism, and maladaptive coping strategies such as heavy alcohol use (Davidson and Foa, 1993). However, when pre-exposure screening has been attempted in high-risk work situations, for example amongst military personnel prior to overseas deployment, the results have been mixed. Within the UK military, prospective studies have found that while there it is possible to identify those at increased risk, screening on the basis of pre-exposure symptoms levels was not helpful in predicting subsequent psychological morbidity (Rona et al., 2006). In contrast, controlled studies undertaken in the US military have found pre-deployment screening was associated with reduced mental health problems (Warner et al., 2011b). A systematic review of pre-employment physical health screening across a variety of civilian occupational settings found that questionnaire based assessments had either no or very weak ability to predict a variety of health and work outcomes (Madan and Williams, 2012).
Concerns regarding the use of pre-employment screening go further than a lack of proven efficacy. Even if a pre-employment screen is able to identify workers who are at increased risk, there will be variations in the positive predictive value of any measure or group of measures. As a result, any pre-employment test used to exclude candidates being offered a position will mean some individuals who would have remained healthy will miss out on potential career opportunities.
In spite of a lack of proven efficacy, pre-employment screening which alleges to test for vulnerability to mental disorder remains common amongst emergency service and first responder organisations. Establishing which, if any, pre-employment screening measures are reliably able to predict mental health outcomes amongst emergency service workers is an essential first step in deciding whether the benefits of pre-employment testing outweigh the potential risks and costs.
The aim of this systematic review is to determine the effectiveness of pre-employment or pre-duty screening as predictors of mental disorder amongst emergency service workers. While we considered all mental disorders in this systematic review, given that depression, anxiety, adjustment disorders and post-traumatic stress disorders are known to be the most prevalent mental disorders amongst emergency workers, we focused particularly on studies measuring these outcomes. To the best of our knowledge this is the first systematic review of pre-employment screening in the emergency services.
Section snippets
Search strategy
Systematic searches were conducted in MEDLINE, PsycINFO and EMBASE electronic databases. A comprehensive range of subject headings and key words combining emergency personnel (e.g. firefighters, police officers, paramedics, first responders), pre-employment screening or risk prediction measures, mental health outcomes and prospective study design were devised for each database (see Supplementary Table 1 for the full search strategy).
Inclusion criteria
The criteria for full text articles to be included in this
Results
A total of 320 research papers were identified by the search strategy. Of these, 21 prospective cohort studies were found to meet all of the inclusion criteria. Fig. 1 demonstrates the flowchart of the selection process. There was a high level of consensus between the researchers regarding which studies meet the inclusion criteria, with a kappa coefficient of 0.89 following the initial screening.
A summary of each of the 21 relevant studies identified is provided in Supplementary Table 2. All of
Discussion
To the best of our knowledge, this is the first systematic review investigating the utility of pre-employment and pre-duty mental health screening amongst emergency services personnel. We were able to identify and combine findings from 21 prospective cohort studies which followed trainee police officers and/or firefighters for their first one to four years of service. In general, dynamic measures including physiological responses to simulated trauma (e.g. HPA activity or skin conductance) and
Funding and disclosures
This project was supported by funding from Department of Health New South Wales. The authors remained independent of the funder in their reporting of results.
Conflicts of interest
The authors declare that they have no conflict of interest relevant to this report.
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