Insomnia and Mental Health in Firefighters

According to the Cleveland Clinic, sleep habits can be unique – some people naturally go to bed and rise early while others naturally go to bed and rise late…an important consideration in a world that sometimes ‘labels’ people with different sleep habits. Insomnia can be acute (short-term), or chronic (long-term) and either primary, meaning that it happens on its own, or secondary, meaning that it is caused by something else. About 30% of adults have insomnia and about 10% have the chronic type, which means that they meet the criteria for insomnia disorder. A diagnosis of chronic insomnia requires that the insomnia cannot be explained by circumstances that would otherwise disturb sleep, that the insomnia occur at least three times per week, and that it must last for at least three months.

Individual sleep patterns are inextricably linked to circadian rhythm, our unique internal clock that operates on an approximate 24-hour schedule and regulates many of our biological processes. Many things can affect sleep, e.g. caffeine, long-distance travel, diet, stress, medication, and shift work. If there’s anything to know about sleep, however, it’s that sleep should be regular, and it should be uninterrupted.

A 2024 paper published on PubMed attempted to review “The Cyclical Battle of Insomnia and Mental Health Impairment in Firefighters.” The authors quickly acknowledge the physical and psychological challenges of firefighting, especially, to their credit, the effects of a frequently and rapidly elevated sympathetic nervous system brought about by the “loud shrilling emergency alerting alarms”. The sympathetic nervous system is responsible for our body’s ‘fight or flight’ responses.

The alarms combine with the otherwise constant state of alertness required of firefighters to misalign the circadian rhythm and impair sleep in the station as well as at home.

Proper sleep requires cycles of rapid eye movement (REM) and non-rapid eye movement (NREM) about every 90-120 minutes. It takes about one hour to reach NREM sleep. According to the authors, “REM sleep occurs after slow-wave sleep and allows for emotional memory processing, while NREM sleep is required for optimal wakefulness and cognitive function the following day.” The authors note that it’s the NREM sleep which is required for the work of firefighting, but it’s REM sleep that’s required for firefighter long-term psychological and physical health. They suggest this as a possible explanation for the prevalence of insomnia in firefighters and its link to such mental health conditions as post-traumatic stress disorder (PTSD), depression, anxiety, and substance abuse.

There are three questionnaires most often used in assessing sleep patterns in firefighters; the Pittsburgh Sleep Quality Index (PSQI); the Epworth Sleepiness Scale (ESS), and; the Insomnia Severity Index (ISI). Use of these, alone or together, in the firefighter population (active and retired) has resulted in findings of poor sleep quality in firefighters ranging from 52% to 73%. One study of Canadian firefighters found that 69% reported “fair” to “very poor” sleep quality while 21.3% had clinical insomnia based on ISI scores.

It’s not really surprising that firefighters are more likely to experience PTSD, anxiety and depression. One study mentioned in the paper found that 53% of firefighters experienced symptoms of Generalized Anxiety Disorder, and a meta-analysis of first responders found that 60% had mild anxiety, 27% had moderate anxiety, and 14% were severely anxious.

The paper cites a study in the U.K. wherein 46% of firefighters said their mental health was a significant factor in sleep disturbance. Firefighters have subjectively reported that increased stress yields increased sleep disturbance. In fact, the paper cites a National Canadian Mental Health Survey finding that firefighters with insomnia were 7.15 times more likely to suffer from Generalized Anxiety Disorder than firefighters who were not experiencing insomnia.

With respect to depression, the authors suggest that the 12-month depression prevalence in firefighters can approach 40% compared to about 6% in the general population. One study apparently sampled 169 firefighters who were exposed to a traumatic event, and found that 53.3% reported depression, and, more strikingly, 57% met the criteria for a PTSD diagnosis.

There’s an established, strong link between depression and insomnia. When one study mentioned assessed firefighters from the National Canadian Mental Health Survey, it found that firefighters with insomnia were 7.91 times more likely to suffer Major Depressive Disorder than firefighters who were not experiencing insomnia. The thinking is that insomnia increases depression risk by impairing emotional regulation.

The authors also discussed PTSD, Obsessive-Compulsive Disorder (OCD), suicide and substance abuse, in each case finding an increased prevalence among firefighters, and linking symptom severity to sleep deprivation for each one except OCD. Specifically, the authors state that, “mental health conditions such as anxiety, depression, PTSD, substance abuse, and suicide risk factors are often comorbidities of each other and with sleep disturbance.”

Several considerations are offered as pathways toward the resolution of the mental health issues experienced by firefighters, especially those compounded by insomnia.

Anxiety sensitivity, i.e. fear of arousal-related situations, can be assessed using the anxiety sensitivity index (ASI-3) and has a reciprocal relationship with mental health issues. This means that it may be useful as both a screening tool and as an intervention. This is especially so given that anxiety sensitivity is also strongly linked to insomnia.

Emotional regulation, the ability to control one’s emotions, and; emotional intelligence, the ability to recognize one’s own emotions and the emotions of others then label them and use the information to make rational decisions, are both discussed as mediators. Some mental health symptoms can impair emotional regulation leaving people less equipped to deal with negative emotional states and, therefore, subject to disrupted sleep and insomnia. People with higher emotional intelligence may have blunted stress responses.

Distress tolerance, a person’s ability to manage negative emotional states, has been linked to mental health. Lower distress tolerance is associated with an increase in mental health concerns. The converse is also true, and firefighters with high distress tolerance had reduced risk for alcohol abuse. The authors found that, “Distress tolerance has been negatively associated with numerous other mental health concerns, including PTSD and anxiety.”

The report includes a table that outlines the results of several interventions on mental health and sleep on full-time firefighters specifically, but overall the authors recommended regular high-intensity exercise as a suggested intervention for both mental health and insomnia – though even medium and low intensity exercises were better than none. With exception of seeking professional assistance, it seems that exercise might be the single, most-controllable efficacious intervention that firefighters can do when faced with mental health and insomnia challenges.

You can read the study at: The Cyclical Battle of Insomnia and Mental Health Impairment in Firefighters: A Narrative Review – PMC

You can read about insomnia at: Insomnia: What It Is, Causes, Symptoms & Treatment

SOURCE: Dan Haden, Editor