Prevalence of post-traumatic stress disorder in firefighters and its associated psychosocial and organizational factors: a scoping review

Abstract

Objective  To map Post-Traumatic Stress Disorder (PTSD) prevalence among firefighters and to identify associated psychosocial, organizational, and sociodemographic factors.

Methods  This scoping review was conducted according to the JBI methodology and the PRISMA-ScR guidelines, searches encompassed nine databases (PubMed, VHL, Cochrane, Web of Science, Scopus, SciELO, PsycINFO, Embase, and OpenBDTD) for studies published from 2014 to 2024. Primary quantitative studies reporting PTSD prevalence among active firefighters or first responders with firefighting duties were included.

Results  After screening, 43 studies were included, reporting a PTSD prevalence ranging from 15% to 30%. Key associated factors included exposure to traumatic events, irregular shifts, sleep deprivation, and organizational stressors. Stigma emerged as the main barrier, and other aspects of firefighters’ lives are negatively impacted. Female firefighters showed a higher PTSD prevalence, often linked to experiences of harassment and discrimination. Specific organizational characteristics were related to worsening symptoms and lower help-seeking.

Conclusions  The findings indicate a high PTSD prevalence among firefighters, underscoring the need for organizational interventions, leadership support, stigma reduction strategies, and expanded access to mental health services.

Keywords:
Firefighters; Mental Health; Post-Traumatic Stress Disorders; Psychosocial Factors; Occupational Health; Scoping Review

Resumo

Objetivo  Mapear a prevalência de transtorno de estresse pós-traumático (TEPT) entre bombeiros e identificar os fatores psicossociais, organizacionais e sociodemográficos associados.

Métodos  Revisão de escopo conforme a metodologia do Joanna Briggs Institute e as diretrizes PRISMA-ScR, com buscas em nove bases de dados (PubMed, VHL, Cochrane, Web of Science, Scopus, SciELO, PsycINFO, Embase e OpenBDTD) para estudos publicados de 2014 a 2024. Foram incluídos estudos quantitativos primários relatando a prevalência de TEPT entre bombeiros na ativa ou socorristas com atribuições de combate a incêndio.

Resultados  Após a triagem, 43 estudos foram incluídos, relatando prevalência de TEPT de 15% a 30%. Os principais fatores associados incluíram exposição a eventos traumáticos, turnos irregulares, privação de sono e estressores organizacionais. O estigma emergiu como a principal barreira, e outros aspectos da vida dos bombeiros são impactados negativamente. A prevalência de TEPT foi maior no sexo feminino, frequentemente associada a experiências de assédio e discriminação. Características próprias da corporação foram relacionadas ao agravamento dos sintomas e à menor procura por ajuda.

Conclusões  Os achados indicam elevada prevalência de TEPT entre bombeiros, ressaltando a necessidade de intervenções organizacionais, apoio da liderança, estratégias de redução do estigma e ampliação do acesso a serviços de saúde mental.

Palavras-chave:
Bombeiros; Saúde Mental; Transtorno de Estresse Pós-Traumático; Fatores Psicossociais; Saúde do Trabalhador; Revisão de Escopo

Introduction

Firefighters are routinely exposed to hazardous situations and extreme operational challenges, which may adversely affect both their physical and mental health. As emergency responders, they are typically the first professionals to arrive at chaotic scenarios, thereby facing continuous exposure to traumatic experiences such as victim rescue operations, large-scale firefighting, and responses to natural disasters. Consequently, these professionals are particularly vulnerable to post-traumatic stress disorder (PTSD)¹.

PTSD is a condition that develops following exposure to a traumatic event. It is characterized by intrusive symptoms like nightmares and flashbacks, avoidance of trauma-related stimuli, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity².

The World Health Organization (WHO) recognizes that catastrophes and recurring natural disasters have a significant emotional impact³, particularly on firefighters. Obuobi-Donkor et al.⁴ examined the prevalence and determinants of PTSD in military personnel and firefighters, reporting a prevalence of 57% in this occupational group. This number is notably higher than the 3% to 6%⁵ lifetime prevalence observed in the general population. Such a disparity highlights the epidemiological relevance of PTSD within this profession and reinforces its characterization as a significant occupational health problem. Consequently, there is an urgent need to unravel the specific contributing factors to PTSD in this professional context⁶.

Studies identify that overwork, insufficient rest, workplace harassment, and discrimination adversely affect firefighters’ mental health and are associated with an increase in PTSD and other mental disorders⁷-¹². All these factors affect the psychological well-being of firefighters¹¹, revealing a lack of psychological support. The stigma surrounding mental disorders in this population poses barriers to effective case management and difficulties in accessing mental health care⁶,¹³.

Although the PTSD prevalence is higher among firefighters and other emergency workers than in the general population, most reviews focus on mixed populations or address risk factors in isolation¹³, which indicates that the literature still lacks integrative synthesis addressing the full spectrum of psychosocial and organizational dimensions linked to PTSD prevalence in firefighters, as well as the identification and categorization of psychosocial, institutional, and sociodemographic factors. As a result, it is necessary to develop approaches that enhance these professionals’ access to mental health treatment.

Given that effective mental health strategies are essential to mitigate the vulnerability and health impacts faced by firefighters, this scoping review aims to map the prevalence of Post-Traumatic Stress Disorder (PTSD) among firefighters and identify associated psychosocial, organizational, and sociodemographic factors.

Methods

Protocol and registration

The review protocol was registered in the Open Science Framework (OSF)¹⁴, in September 2024 (DOI: https://doi.org/10.17605/OSF.IO/AJ3P4), in accordance with PRISMA-ScR guidelines¹⁵. The study addressed the following research questions: What is the prevalence of PTSD among firefighters? Which psychosocial and organizational factors are associated with PTSD development? What sociodemographic characteristics are reported among affected individuals? Which intervention models or health policies have been described in the literature to prevent PTSD and other mental disorders in firefighters?

Eligibility criteria

Study selection was based on predefined eligibility criteria (EC) and followed the PCC (Population, Concept, Context) mnemonic framework. The population included active firefighters and first responders engaged in firefighting operations. The concept comprised PTSD. The context encompassed PTSD prevalence, associated factors, and exposure-comorbidity relationships within occupational settings, with emphasis on traumatic exposure, working conditions, and mental health support structures. Studies published in English, Portuguese, Spanish, and French were eligible.

Information sources

A preliminary search across international databases (PROSPERO, PubMed, Joanna Briggs Institute, Epistemonikos, American Psychological Association, PsycInfo, and Cochrane Library) did not identify reviews of a comparable scope to this study. Subsequently, Embase (Ovid), PsycINFO (Ovid), PubMed (EBSCOhost), the Virtual Health Library (VHL/BVS – EBSCOhost), the Complementary Medicine Database, MEDLINE (EBSCOhost), CINAHL (EBSCOhost), Scopus, Scientific Electronic Library Online (SciELO), and Web of Science (WOS) were systematically searched. Gray literature was also included through the Cochrane Database of Systematic Reviews (CDSR) and the Brazilian Digital Library of Theses and Dissertations (BDTD). Searches were conducted from May 3 to August 28, 2024, as studies published between 2014 and 2024.

Search strategy

The Joanna Briggs Institute (JBI) methodology for scoping reviews¹⁶ emphasizes comprehensive search strategies to map the full extent of available evidence, including gray literature. Accordingly, relevant Medical Subject Headings and Health Sciences Descriptors (MeSH/DeCS), as well as free-text terms related to PTSD, firefighters or first responders, and PTSD prevalence, were used, following approaches described in previous scoping reviews (e.g., Jones et al., 2020)¹⁷.

Searches covered the entire available period for each database, ensuring that the information was up to date in an evolving research field. The complete search strategy, including descriptors, databases, filters, and Boolean operators, is summarized in Table 1.

Table 1
Search strategy and descriptors

Strategy	Descriptors	Input terms
Participant	Firefighters AND (MeSH terms)	Firefighters OR Firefighter OR “Fire and Rescue Personnel” OR “Fire Fighters” OR “Fire Fighter OR “Emergency Responders” OR “Emergency Responder” OR “Responder, Emergency” OR “Responders, Emergency” OR “Emergency First Responders” OR “Emergency First Responder” OR “First Responder, Emergency” OR “First Responders, Emergency” OR “First Responders” OR “First Responder” OR “Responder, First” OR “Responders, First”.
Concept	Post-traumatic stress disorders AND (MeSH terms)	“Stress Disorders, Post-Traumatic” OR “Post-Traumatic Stress Disorder” OR “Post-Traumatic Neuroses” OR PTSD OR “Posttraumatic Neuroses” OR “Post-Traumatic Stress Disorders” OR “Post Traumatic Stress Disorders” OR “Posttraumatic Stress Disorders” OR “Posttraumatic Stress Disorder” OR “Post Traumatic Stress Disorder” OR “Delayed Onset Post-Traumatic Stress Disorder” OR “Delayed Onset Post Traumatic Stress Disorder” OR “Chronic Post-Traumatic Stress Disorder” OR “Chronic Post Traumatic Stress Disorder” OR “Moral Injury” OR “Moral Injuries” OR “Acute Post-Traumatic Stress Disorder” OR “Acute Post Traumatic Stress Disorder” OR “Stress Disorders, Traumatic” OR “Traumatic Stress Disorder” OR “Traumatic Stress Disorders”
Context	Prevalence AND (MeSH terms)	Prevalence OR Prevalences OR “Point Prevalence” OR “Point Prevalences” OR “Period Prevalence” OR “Period Prevalences”
General Search	Operator Combination	firefighters (all terms) AND Post-traumatic stress disorders (all terms) AND prevalence (all terms)
	Database	EMBASE (OVID platform), PsycINFO (EBSCOhost platform), PubMed (EBSCOhost platform), VHL (EBSCOhost platform), Scopus, SciELO, Web of Science (WOS), Cochrane (Cochrane Database of Systematic Reviews (CDSR), Thesis and Dissertation Database (TDDb).
	Filters	Title, Abstract, language and period 2014–2024, English, French, Portuguese and Spanish.

Selection of sources of evidence

The search and selection process followed three steps: (1) identification, (2) screening of eligible publications, and (3) data extraction. All records were exported to Rayyan®¹⁸for further analysis (management and screening). The flow of information through the identification, screening, eligibility, and inclusion phases followed PRISMA-ScR guidelines. Screening involved reference management with automated tools, duplicate removal, exclusion of ineligible records during calibration, and analysis of studies meeting the eligibility criteria. Studies were excluded if they: (a) did not include active firefighters or first responders with firefighting duties; (b) did not assess PTSD or used non-validated instruments; (c) did not report prevalence or associated factors; (d) used qualitative designs, review formats, case reports, or other non-primary evidence; (e) lacked full-text availability; or (f) evaluated populations unrelated to fire services. These criteria were applied at both the title/abstract screening and full-text eligibility stages. Researchers (ASOA) and (SRL) participated independently in the selection process. First, titles and abstracts were analyzed separately to identify articles meeting the inclusion criteria. Second, the full texts of the selected studies were read in their entirety to confirm eligibility. Disagreements were resolved by consensus. The study selection process is presented in the PRISMA-ScR flowchart (Figure 1).

Figure 1
Scoping Review flowchart.

Data charting and extraction

Data extraction was performed independently by researchers (ASOA) and (SRL) using Rayyan®¹⁸ and subsequently organized in Microsoft Excel®¹⁹. Selected articles were retrieved by the reviewers and entered into the data charting form. To ensure consistency and clarity, the form was independently assessed by reviewers.

Data items and variables

The following variables were extracted from each included source of evidence: author(s), year of publication, country of study, reported PTSD prevalence, sample size, Quality Appraisal Level (QAL), study design, objectives, and main results. Additionally, population characteristics (e.g., gender, years of service), instruments used for PTSD assessment, and psychosocial and organizational factors associated with PTSD were analyzed. However, they were not explicitly presented in the table. To preserve methodological accuracy, no assumptions or data simplifications were applied during extraction, as the review focused on capturing quantitative data directly related to the review questions as reported in the original studies.

Critical appraisal of individual sources of evidence

The methodological quality of the included studies was assessed using the JBI Critical Appraisal Checklist for Prevalence Studies, expressed as a Quality Appraisal Level (QAL). The reviewers independently evaluated the studies and resolved any discrepancies (ASOA) and (SRL). Each criterion was classified as ‘Yes’, ‘No’, or ‘Unclear’, and the total number of affirmative responses was used to determine the overall quality level. As part of the appraisal process, it was assumed that the included studies reported PTSD symptoms. When relevant data were missing or unclear, these issues were documented and resolved by consensus between the reviewers.

Thematic patterns related to psychosocial, organizational, and sociodemographic factors were subsequently integrated through descriptive narrative synthesis and labeled according to the appraisal criteria.

Studies meeting ≥70% of the criteria were classified as high quality, those meeting 50-69% as moderate quality, and those meeting <50% as low quality. Low-quality studies were not excluded; however, their findings were interpreted with caution, considering the specificities and limitations of each study design.

The results were synthesized to highlight potential weaknesses and to avoid overinterpretation of findings.

Details on data handling and summarization are provided in the Data synthesis subsection. Quantitative variables were organized into structured tables to facilitate comparison of prevalence estimates, and assessment instruments across studies while preserving the methodological heterogeneity inherent to scoping reviews.

Data synthesis

Relevant variables were extracted and standardized. Prevalence values, sample characteristics, study designs, and assessment tools were tabulated to enable structured comparison across studies. For synthesis, quantitative data were summarized descriptively. Psychosocial, organizational, and sociodemographic factors were identified and grouped into thematic categories using an inductive approach conducted by reviewers.

To illustrate this distribution, a world map was created to show the geographic distribution of the included studies. For descriptive and illustrative purposes, green shading indicates countries and regions where studies were identified. Graphical panels display the aggregated sample size by region and the proportional contribution of each area to the total sample. Data were initially organized in Microsoft Excel® and subsequently imported into geographic mapping software (QGIS, version Changelog for QGIS 3.44)²⁰. The mapped variables included country and continent, while complementary panels displayed aggregated sample size and mean reported PTSD prevalence included country and continent, while complementary panels displayed aggregated sample size and mean reported PTSD prevalence by continent. Figure 2 presents these data by country and continent together with the mean sample size and mean PTSD prevalence, providing a visual summary aligned with the aims of the review.

Figure 2
Distribution of selected studies in scoping review, by design and geographic location

(A) percentage distribution of studies designs; (B) geographic distribution of studies by country and continent on global map; (C) proportional distribution of studies designs by continent; and (D) average distribution of studies sample sizes by continent (outer circle) and average PTSD prevalence by continent (inner circle).

Results

Selection of sources of evidence

The search retrieved 981 records across databases, of which 459 duplicates were removed. Of the remaining 522 records, titles and abstracts were screened, and 208 were excluded, primarily because the study population did not meet the inclusion criteria, due to inappropriate populations or the absence of PTSD assessment.

Of the 314 records assessed for full-text eligibility, 250 were excluded for reasons including inappropriate outcomes, population mismatch, inadequate study design, insufficient data, use of non-validated PTSD instruments, or being outside the scope of the review. Thus, 64 full-text articles were examined, of which 21 were review articles and were therefore excluded. Thereafter, the analysis focused on the characteristics of the remaining studies on PTSD, after which five additional records identified through other sources as gray literature (BDTD) were assessed and excluded for failing to meet the final criteria.

A total of 43 studies met the eligibility criteria and were included in this scoping review. The analysis focused on studies that addressed PTSD as a primary outcome and examined its associations with psychiatric, behavioral, and occupational comorbidities, including depression, sleep disorders, alcohol use, and burnout among firefighters. Figure 1 presents the scoping review flowchart.

Characteristics of sources of evidence

This review included only primary quantitative studies published in English, Portuguese, Spanish, or French between 2014 and 2024 that used validated or standardized instruments to assess PTSD. Studies were excluded that focused on emergency workers without firefighting tasks. Qualitative studies, reviews, case reports, dissertations, conference abstracts, editorials, and other non-primary evidence materials were excluded, as were studies for which the full text was unavailable. The process adhered to the PRISMA ScR framework as depicted in Table 1. The file containing the search strategy was deposited in the SciELO repository and is publicly available in Google Drive®.

Critical appraisal of sources of evidence

The 43 included studies examined PTSD prevalence among firefighters or first responders with firefighting duties. Key study characteristics, such as sample size, objectives, instruments, country, QAL rating, prevalence, and associated factors, are summarized in Table 2. Additional aspects, including psychosocial and organizational factors related to PTSD in fire departments, assessment tools, associated prevalence, and main findings, were analyzed but were not presented in the table. The review categorized the selected articles by design, in line with the standard classification used in the field of epidemiological health research.

Table 2
General design and main findings in scoping review

Author(main)( ), (year)	Sample Size – PTSD prevalence (%)	Quality Appraisal Level*	Design – country	Objectives	Main results
Schnell, Suhr, Weierstall-Pust6, (2020)	232 – 12.5%	High	Cross-sectional - Germany	To investigate PTSD prevalence, influence, and risk and protective factors (such as resilience and sense of coherence).	The high presence of PTSD in firefighters reinforces the importance of pre- and post-mission interventions to increase resilience and reduce the effects of traumatic stress.
Langtry et al.7, (2021)	1.300 – 5.6%	Moderate	Cross-sectional - Northern Ireland and United Kingdom	To investigate whether exposure to trauma leads to higher rates of PTSD and complex post-traumatic stress disorder.	About 24% of firefighters met the criteria for PTSD. The risk increased with the number of traumatic events.
Bastug et al.8, (2019)	100 – 40.0%	High	Cohort Cross-sectional - Turkey	To investigate the psychological impacts of the prevalence of PTSD, depression, burnout, low life satisfaction, and secondary trauma on the development of these conditions.	A high rate of PTSD (40%) was associated with higher levels of depression, burnout, and low life satisfaction. This requires preventive interventions and supportive policies.
Jahnke et al.10, (2019)	1.773 – 16.5%	High	Cross-sectional - USA	To investigate the prevalence of chronic discrimination and harassment in female firefighters’ physical and mental health, substance abuse, and job satisfaction.	Female firefighters with higher exposure to discrimination/harassment reported more symptoms of depression, anxiety, PTSD, alcohol use, job dissatisfaction, and family stress, resulting in poor physical and mental health.
Shin et al.11, (2023)	483 – 3.9%	High	Cross-sectional - South Korea	To investigate exposure to traumatic incidents and their consequences on PTSD, post-traumatic growth, and associated factors.	Rotating shifts and length of service directly influence the risk of PTSD and post-traumatic growth and increased the risk of belonging to the groups with the worse symptoms of PTSD.
Khoshakhlagh et al.12, (2024)	2.339 – 29.1%	High	Cross-sectional - Iran	To investigate the relationship between occupational stress, PTSD, musculoskeletal symptoms, and the role of psychological mediators such as burnout and depression.	Occupational stress and PTSD increased the likelihood of musculoskeletal symptoms (34%). Relevant psychological factors, such as burnout and depression, mediated these effects.
Mueller et al.13, (2021)	11.081 – 7.9%	High	Cross-sectional Cohort - USA	To assess symptoms of PTSD, depression, and subjective cognitive concerns in firefighters exposed to the World Trade Center attacks and those with no such exposure.	Firefighters exposed to the World Trade Center attacks had fewer cognitive concerns and a higher prevalence of PTSD and depression.
Oliveira et al.21, (2023)	130 – 9.2%	High	Cross-sectional - Portugal	To investigate the prevalence of PTSD firefighters subjected to cumulative and severe traumatic events after the 2017 wildfires.	Cumulative exposure to traumatic events and individual aspects were associated with the development of PTSD.
Bartlett et al.22, (2018)	765 – 26.6%	High	Cross-sectional – USA	To analyze the high rates of suicidal ideation, tolerance to distress, and the relationship between PTSD symptoms.	The severity of PTSD symptoms is associated with suicide risk due to a low tolerance for suffering. Interventions that increase tolerance for distress can effectively reduce the risk of suicide.
Bezabh et al.23, (2018)	603 – 19.9%	High	Cross-sectional - Ethiopia	To investigate the prevalence and factors associated with PTSD in emergency responders in Addis Ababa.	High prevalence was associated with a family history of mental illness, longer careers, prolonged exposure, and traffic accidents.
Jitnarin et al.24, (2022)	624 – 6.7%	High	Randomized Controlled Trial -USA	To investigate the prevalence of PTSD, related occupational factors, and mental comorbidities.	Firefighters with PTSD have a higher rate of mental comorbidity and stress and low levels of self-efficacy and social support. The study highlighted the need for early and holistic interventions.
Seidman, Born, Corriveau25, (2024)	138 – 21.7%	High	Cross-sectional - USA	To investigate PTSD during the COVID-19 pandemic and the feeling of “professional vocation” as a PTSD and self-efficacy at work moderator.	Professionals with a strong sense of vocation had greater self-efficacy at work in the face of PTSD, protecting them from the negative effects of PTSD on self-efficacy at work.
Ruggero et al.26, (2021)	202 – 19.3%	High	Ecological - USA	To investigate PTSD in World Trade Center respondents according to hyperarousal, intrusions, avoidance, and numbness.	Hyperarousal configured the main predictor of increased PTSD symptoms the day after; hyperarousal-focused interventions can disrupt symptomatic cascades to reduce PTSD.
Chiang et al.27, (2021)	164 – 21.0%	High	Cross-sectional - USA	To investigate the prevalence of subclinical symptoms of PTSD in American firefighters.	Firefighters with PTSD have burnout, lower satisfaction, greater substance use, and signs of exhaustion in the workplace. This requires attention and psychological support for these workers.
Lima, Assunção, Barreto28, (2015)	711 – 6.9%	High	Cross-sectional - Brazil	To investigate the prevalence of depression in firefighters and its association with factors such as post-traumatic stress and alcohol abuse.	The study found a relatively low prevalence of depression in firefighters but a strong association between PTSD symptoms and alcohol abuse with depression.
North, McDonald29, (2023)	124 – 24.0%	High	Cohort - USA	To investigate long-term emotional and psychosocial outcomes and recovery after the Oklahoma City bombing, focusing on psychiatric disorders such as PTSD.	PTSD increased and major depressive disorder quadrupled the prevalence of 50% of PTSD cases. This necessitates ongoing support.
Testoff et al.30, (2024)	515 – 18.2%	High	Cross-sectional - USA	To analyze the prevalence of generalized anxiety disorder, depression, PTSD, and organizational stigma.	U.S. firefighters have high rates of mental disorders and frequent comorbidities and organizational stigma (OR = 5.25) associated with the risk of PTSD. The study suggested eliminating barriers to mental health treatment as prevention.
Boffa Schmidt et al.31, (2017)	893 – 31.8%	High	Cross-sectional – USA	To investigate the association between PTSD symptoms and suicide in U.S. firefighters.	PTSD symptoms were associated with suicide, constituting the strongest predictors together with re-experience, even after controlling for depression and other factors.
Bakirci, Sar, Cetinet32, (2024)	223 – 16.1%	High	Cross-sectional - Turkey	To assess the psychological effects after the Pazarcik and Elbistan earthquakes focusing on trauma, depression, anxiety, stress, and resilience.	Firefighters exposed to earthquake trauma showed increased risk for PTSD, depression, anxiety, and stress. High levels of trauma were associated with elevated PTSD symptoms. Affectivity and cognition were the most psychologically affected domains.
Ask, Gudmundsdottir33, (2014)	465 – 3.1%	High	Longitudinal -Denmark	To investigate the prevalence of PTSD after a fireworks factory explosion.	The 18-month follow-up showed participants’ resistance against the traumatic exposure and a low prevalence of PTSD. Personality factors and external locus of control configured important predictors of PTSD.
Wilson34, (2021)	49 – 16.6%	High	Cross-sectional - USA	To investigate the prevalence and factors associated with PTSD in high-risk workers, especially firefighters.	The study showed a high prevalence of PTSD. The training intervention improved resilience and reduced PTSD symptoms. Such initiatives can reduce psychological impacts.
Lee, Park, Sim35, (2018)	212 – 17.7%	Moderate	Cross-sectional - South Korea	To compare PTSD risk and coping strategies between firefighters and the general population.	Professionals who actively coped by focusing on the problem and social support were associated with fewer PTSD symptoms, suggesting that improving strategies can reduce the psychological impact of traumas experienced at work.
Nascimento et al.36, (2022)	338 – 31.07%	High	Cross-sectional - Brazil	To analyze the prevalence of PTSD and related factors in these professionals.	The prevalence of PTSD was high, especially among those facing life-threatening situations. Strategies such as leaves, psychological support, and reassessment changed scores.
Harvey et al.37, (2016)	753 – 13.0%	High	Cross-sectional - Australia	To assess the prevalence of PTSD, depression, and alcohol abuse and their relation to repeated traumatic exposure in active-duty and retired firefighters.	Exposure to fatal incidents increases PTSD, depression, and binge drinking. Retirees showed a higher prevalence than in active-duty firefighters.
Arbona, Schwartz38, (2016)	551 – 11.3%	High	Cross-sectional – USA	To investigate the associations between clusters of PTSD symptoms and depression, alcohol abuse, and stress.	The PTSD cluster had a strong correlation with depression and alcohol abuse. Symptoms of (re)experience and hypervigilance predicted overall stress. Suggested treatment of PTSD, general stress, and specific symptoms.
Paulus et al.39, (2017)	2.707 – 30.0%	Moderate	Cross-sectional – USA	To investigate the main and interactive effects of depression and PTSD in alcohol dependence.	Depression and PTSD symptoms interact to increase the risk of alcohol dependence. Depression associated with greater alcohol consumption can further worsen the condition.
Zegel et al.40, (2022)	660 – 9.7%	High	Cross-sectional -USA	To investigate mental health correlates in firefighters and whether they show rates of PTSD, alcohol use disorder, and other comorbidities.	Firefighters with PTSD and alcohol use disorder have worse mental health outcomes. Firefighters showed higher levels of depression, sleep disorders, anger, suicidal risk, and occupational stress than the other comparative groups.
Leonard et al.41, (2023)	685 – 9.9%	High	Cross-sectional -USA	To investigate whether emotion regulation explains the relationship between PTSD symptoms and alcohol use in firefighters.	Firefighters with more severe symptoms of PTSD were more likely to use alcohol to cope with negative emotions and for emotional coping.
Kaufman et al.42, (2024)	320 – 64.3%	Moderate	Cross-sectional - USA	To investigate the relationship between PTSD clusters and spirituality/religion with alcohol use in first responders.	The symptomatology of the intrusion cluster was associated with greater alcohol use. Positive spiritual coping protected against alcohol abuse, whereas negative coping and religiosity increased its risk.
Smith et al.43, (2018)	639 – 9.9%	High	Cross-sectional -USA	To investigate the relationship between PTSD, alcohol use, and reasons for consumption, focusing on the moderating role of sleep disturbance.	Sleep disturbance intensifies PTSD symptoms and the use of alcohol to cope with negative emotions.
Kim JI, Park, Kim JH44, (2018)	7.190 – 5.2%	High	Cross-sectional - South Korea	To investigate the relationship between PTSD, alcohol use disorders, insomnia, and suicidal ideation.	Alcohol use disorders and insomnia mediate the relationship between PTSD and suicidal ideation.
Khumtong, Taneepanichskul45, (2019)	1.215 – 6.4%	High	Cross-sectional - Thailand	To analyze the relationship between PTSD and sleep quality in urban firefighters in Bangkok.	Firefighters with PTSD have a higher prevalence and poor sleep quality. Improving their health requires psychological interventions.
Healy, Vujanovic46, (2021)	802 – 9.2%	High	Cross-sectional USA	To assess whether sleep disturbances moderate PTSD and suicide.	Sleep disorders increase the association between PTSD and suicide, even after controlling for occupational stressors and trauma, requiring interventions related to sleep disorders.
Bertolazi et al.47, (2022)	370 – 31.9%	High	Cross-sectional - Brazil	To assess PTSD prevalence and sleep quality (daytime dysfunction) in firefighters after a fire in a nightclub in Brazil.	Firefighters showed a high prevalence of PTSD one year after helping the victims of the fire at the Kiss nightclub (which occurred in 2013 in southern Brazil). Factors such as gender, shift work, sleep problems, and previous psychiatric history were associated with poor sleep quality.
Park et al.48, (2019)	45.698 – 2.6%	High	Cross-sectional - South Korea	To investigate the prevalence of suicidal ideation in South Korean firefighters and the occupational and clinical factors (PTSD) that may influence this behavior.	Firefighters showed a higher prevalence of suicidal ideation than the general population, which was associated with PTSD. Factors such as recent trauma, occupational stress, emotional burden, and symptoms of PTSD and depression configure important correlates.
Stanley et al.49, (2019)	1040 – 30.4%	High	Cross-sectional – USA and Israel	To examine whether protective factors such as a sense of belonging and social support reduce the severity of PTSD symptoms.	Social support, particularly from supervisors, was strongly associated with reduced PTSD severity. After the intervention, prevalence decreased from 30.4%. Promoting mental health in the workplace configures an effective strategy to reduce PTSD.
Jones et al.50, (2018)	220 – 25.6%	High	Descriptive - USA	To examine PTSD prevalence and factors correlated with psychiatric symptoms, in firefighters and emergency medical technicians in a southern U.S. state.	The study showed a high prevalence of mental disorders, including PTSD, sleep disorders (93%), anxiety symptoms (28%), and suicide risk (34%). It also highlighted the need for dedicated and eminent mental health approaches.
Lee51, (2019)	545 – 19.0%	Moderate	Cross-sectional - South Korea	To investigate how perceived social support can reduce PTSD via intrusive rumination and feelings of entrapment.	Perceived social support reduces PTSD and configures a resilience factor that moderates the effects of trauma and mitigates the negative effects of entrapment feelings.
Huang et al.52, (2019)	409 – 10.8%	High	Cross-sectional, Cohort - China	To investigate the relationship between personality traits, conscientiousness, and PTSD in young Chinese firefighters, focusing on the mediating role of perceived social support.	Conscientiousness has a negative correlation with PTSD. Social support from peers and supervisors plays an important role in reducing PTSD symptoms, unlike family support.
Senger et al.53, (2023)	155 – 5.6%	High	Cross-sectional -USA	To investigate associations between resilience, hope, and mental and physical health, focusing on chronic pain, well-being, and posttraumatic growth.	Resilience configured a negative predictor of PTSD and chronic pain, whereas hope, a positive predictor of well-being and posttraumatic growth. Promoting resilience and hope can improve firefighters’ mental and physical health.
De Haart et al.54, (2021)	502 – 2.2%	Moderate	Cohort - Netherlands	To investigate whether avoidance learning decreases the development of PTSD symptoms in firefighters over two years.	Evidence associated avoidance learning with previous PTSD symptom severity. Future development of PTSD symptoms may occur.
Gulliver et al.55, (2021)	322 – 1.18%	Moderate	Longitudinal - USA	To examine how exposure to potentially traumatic events influences the emergence of PTSD, depression, and psychological distress in firefighters in the first three years of their careers.	Inexperienced firefighters exposed to trauma showed a low prevalence of PTSD and depression and stable psychological distress over time. The outcome was more associated with personal traits than with variation in trauma exposure. The group showed remarkable resilience.
Kim, JE. et al.56, (2018)	37.093 – 5.4%	High	Cross-sectional - South Korea	To investigate rates of PTSD and how stigma and barriers to access to treatment negatively affect firefighters’ health.	Stigma constituted a factor for seeking no help. Only 9.7% of firefighters with PTSD received treatment in the month prior the evaluation.

• PTSD: Post-Traumatic Stress Disorder
• * Quality Appraisal Level (QAL) - Each criterion was rated as ‘Yes’, ‘No’, or ‘Unclear’. The total number of affirmative responses was converted into a quality level: studies meeting (≥70%) of the criteria were rated as high quality, (50–69%) as moderate quality, and (<50%) as low quality.

Results of individual sources of evidence

PTSD in firefighters is a complex and multifactorial phenomenon influenced by psychosocial²¹, occupational²², and environmental factors²³. An overview of the studies analyzed shows that the main triggering factors were associated with exposure to traumatic situations²¹,²², disasters²³,²⁴, pandemic contexts²⁵, psychosocial and organizational conditions, as well as the dynamics of stress symptoms over time²⁶,²⁷. Many of these elements are indirectly related to environmental factors.

In addition to diagnosis, prevalence, and treatment, the literature emphasizes the importance of preventive occupational measures. These include identifying underlying causes ²²,²⁶, managing risk factors and comorbidities²⁸,²⁹, addressing stigma as a barrier to care³⁰,³¹, and mitigating exposure to traumatic events³². The most frequently reported PTSD-associated comorbidities/signal included depression²⁸, burnout syndrome⁰⁸, alcohol abuse³⁷-⁴⁴, sleep disorders⁴⁵-⁴⁷, and suicidal ideation⁴⁸.

Psychosocial factors in the workplace comprised discrimination and harassment⁴⁹, occupational stress⁵⁰, and exposure to severe traumatic incidents⁵¹. Conversely, mitigating factors included social support and individual resilience⁵¹-⁵³. Coping strategies and skills aimed at recovery and well-being also emerged among firefighters with PTSD⁵⁴,⁵⁷, particularly during the initial stages of their career⁵⁵.

Consequently, greater symptom severity has been associated with functional impairment and increased exposure to stigma within fire services⁵⁶.

The evidence also underscores the relevance of organizational policies addressing trauma exposure and psychological support before, during, and after active service, as well as during retirement²³,³⁵,³⁷,³⁹,⁴⁹. In this context, workplace management structures designed to provide effective psychological support²⁴,³⁸,⁴⁰,⁴⁴,⁵⁰ were emphasized.

Subgroup analyses targeted specific populations, including male³⁸,⁵⁴ or female firefighters¹⁰, volunteers⁶, wildfire suppression personnel²¹, and urban search and rescue teams³². In addition, some investigations compared these different populations, how for example, a South Korean study compared firefighters with the general population³⁵, another compared people exposed to the World Trade Center attacks¹³, and a third one compared firefighter from different countries⁹.

To do that, the included studies used diverse research designs, focusing on specific disasters³³: the World Trade Center attacks in the USA²⁶, the Kiss nightclub fire in Brazil⁴⁷, the Oklahoma City bombing in the USA²⁹, and the covid-19 pandemic²⁵.

Several investigations did not describe personalized actions or interventions tailored to the work environment or to individual firefighter characteristics, despite evidence that such factors may influence life satisfaction¹¹ and the need for mental health care⁵⁶, whether for prevention or rehabilitation¹².

In addition, some studies showed national contexts and encompassed diverse global regions, including North and South America, Europe, Asia (East, Southeast, and Middle East), Oceania, and Africa. The United States¹⁰,¹³,²²,²⁴ accounted for the largest number of publications, followed by South Korea⁴,¹¹,³⁵,⁴⁴,⁴⁸,⁵¹, Brazil²⁸,³⁶,⁴⁷, and Turkey⁸,³². Other countries, such as Germany⁵, Portugal²¹, the United Kingdom⁹, Denmark³³, the Netherlands⁵⁴, Iran¹², Thailand⁴⁵, Australia³⁷, China⁵², and Ethiopia²³, also reported findings on their firefighter populations. One study involved interregional collaboration, specifically between the USA and Israel⁴⁹.

Figure 2 illustrates the global distribution of the included studies, along with descriptive summaries of the other variables.

In summary, methodologically, most studies employed cross-sectional designs⁶,⁹-¹²,²¹-²⁵,²⁷-²⁸,³⁰-³²,³⁴-⁴⁹,⁵¹,⁵³,⁵⁶ (76.74%), followed by cohort⁸,²⁹,⁵²,⁵⁴ (11.63%) and specify longitudinal approaches¹³,³³,⁵⁵ (4.65%), while others represent smaller proportions. Geographically, the Americas (North and South) led the volume of PTSD research. Multivariate studies are concentrated in North America and Europe. The highest PTSD prevalence was concentrated in Western Asia (28.90%) and Oceania (25.60%), and the largest sample sizes are concentrated in East Asia (13,090), North America (1,215), and Southeast Asia (1,114).

Quality appraisal of included studies

The critical appraisal of the included studies was conducted using the Quality Appraisal Level (QAL); thus, it considers the clarity of objectives, sample size, instruments, outcomes, and the completeness of methodological reporting. Design variations were also considered when interpreting differences in prevalence. Based on these criteria, high-quality studies were characterized by clear objectives, adequate sample sizes, validated instruments, and well-defined outcomes.

Moderate-quality studies relied mainly on alternative instruments and self-reported measures; in these studies, standardized instruments were used, but the strength of the evidence supporting the findings was limited. Low-quality criteria involved substantial missing information across more than three methodological domains. Overall, most studies were classified as high quality, and the QAL ratings are presented in Table 2.

In terms of quality distribution, of 43 included studies, 36 were rated as high quality⁶,⁸,¹⁰-¹³,²¹-³⁴,³⁶-⁴¹,⁴³-⁵⁰,⁵²-⁵³,⁵⁶, and 7 as moderate⁹,³⁵,³⁹,⁴²,⁵¹,⁵⁴,⁵⁵. No studies were classified as low quality.

Regarding assessment methods, most high-quality studies employed standardized PTSD assessment instruments (e.g., PCL-5) and examined more than one psychosocial factor potentially associated with PTSD symptoms. Two studies⁴⁵,⁵¹ did not use validated instruments for PTSD assessment. Others relied on diagnostic criteria related to the organizations⁶,⁹,¹²,²⁴,²⁷-²⁸,⁴⁰,⁴³,⁴⁶,⁴⁸-⁴⁹,⁵¹.

With respect to sample size and analytical robustness, among the 31 studies with large sample sizes (more than 300 participants)⁹-¹³,²²-²⁴,²⁸,³⁰-³¹,³³,³⁶-⁴⁹,⁵¹-⁵²,⁵⁴,⁵⁵,⁵⁶, most analyzed the associated factors appropriately, including depression²⁸,³⁸,⁴⁰, sleep disturbances⁴⁵,⁴⁷, alcohol use³⁹,⁴²,⁴³, social support⁴⁹,⁵², cumulative exposure²¹,³⁷, suicidal ideation²²,⁴⁴,⁴⁶; occupational stress¹²,⁴⁰; rumination³⁵, resilience³³,⁵³; and discrimination among women¹⁰.

The main instruments used to assess PTSD were: the PTSD Checklist (PCL) for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5 )¹³,¹⁸,²¹,²³-²⁸,³¹,³⁴,³⁸,³⁹,⁴¹,⁴⁴; the Life Events Checklist for DSM-5, which emphasizes exposure to traumatic events²²,⁴²,⁴³,⁴⁹,⁵³; the Impact of Event Scale-Revised, measuring intrusion, avoidance, and hyperarousal³⁵,³⁶,⁴⁰; the Posttraumatic Diagnostic Scale, based on DSM-IV criteria⁶; the Post-Traumatic Stress Symptom Scale (focusing on intrusive thoughts and physiological arousal)⁹; and the Trauma Screening Questionnaire¹⁰. Overall, the predominance of high-quality articles reinforces the consistency of the evidence base synthesized in this review.

Synthesis of results

Data extraction

Quantitative data on PTSD prevalence and the psychosocial and organizational factors associated with it among firefighters were synthesized. The synthesis combined quantitative data (QD), summarized in Table 2, with a narrative analysis of recurring themes. Among the cross-cutting findings, stigma emerged as the main barrier to seeking treatment⁴⁴ whereas gender-based discrimination emerged as a psychosocial stressor associated with PTSD prevalence among female firefighters⁸.

Prevalence, amplitude characteristics, and associations

Research on PTSD development in firefighters has reported varying prevalence estimates as a central manifestation of psychological distress. In the included studies, PTSD prevalence ranged from 15% to 30% among firefighters. Many investigations employed different instruments to establish associations and comorbidities, using standardized scales to assess depression²⁸,³⁸, anxiety²⁴,⁵⁰, stress³², sleep quality⁴⁵,⁴⁷, alcohol consumption⁴⁴, emotional difficulties⁴³, and suicide risk²²,³¹,⁴⁶,⁴⁸.

Beyond these clinical correlates, other studies applied instruments addressing lack of social support⁴⁹,⁵², coping strategies³⁵, personality traits and resilience²⁵,³³,⁵³, predictive factors such as somatization³³and intrusive rumination⁵¹, as well as the impact of organizational culture on PTSD development and maintenance³⁰, along with several additional psychosocial and occupational dimensions⁹,¹¹,¹²,²⁹,³²,³³,³⁷,⁵¹.

Taken together, the evidence indicates that PTSD among firefighters is multifactorial³³, associations emerged across multiple domains, including exposure to traumatic factors¹¹,¹²,¹³, disorder severity⁹,³⁴,³⁷, and the relationship between PTSD and physical health¹¹,¹²,⁵⁰. Overall, the synthesized evidence indicates that PTSD among firefighters is multifactorial³³, driven by cumulative trauma exposure, organizational culture, and psychosocial stressors.

These findings address the initial research questions by mapping prevalence trends, identifying predictive factors, and highlighting knowledge gaps to inform future interventions.

Discussion

Summary of evidence

The PTSD prevalence identified in this review aligns with previous literature, which consistently reports higher prevalence in firefighters than in the general population⁴-⁵. Repeated exposure to traumatic events remains the central trigger of PTSD among firefighters, as documented across multiple studies¹¹-¹³.

It was evidenced that PTSD is associated with exposure to traumatic events, and risk is heightened by psychosocial and organizational factors²¹-²² including lack of institutional support, stigma related to mental disorders⁴⁹ and barriers to accessing treatment⁵⁰,⁵⁶.

Taken together, the evidence indicates that psychological suffering among firefighters involves multiple interacting determinants, requiring comprehensive assessment and intervention strategies capable of addressing clinical, occupational, and cultural dimensions simultaneously.

From an organizational perspective, several factors contribute to sustained psychological strain and restrict recovery opportunities, including irregular shifts, extended working hours, sleep deprivation, and rigid hierarchical structures. In addition, occupational cultures that normalize endurance, discourage help-seeking, and stigmatize mental health problems may exacerbate symptom chronicity. This delay in treatment contributes to the observed prevalence.

Given the complexity of the issue, a broad analytical foundation is necessary, integrating cross-cultural perspectives⁴⁴, diverse operational realities¹⁰, and public mental health policies⁴⁸,⁵⁶. Nevertheless, many studies did not describe key sociodemographic or occupational characteristics³⁶, which limited comparability and hindered the development of more robust conclusions¹⁰,¹³,⁵⁵. As a consequence, the lack of methodological standardization limits cross-study synthesis and highlights persistent psychosocial risks⁵⁷by constraining the ability to describe practical solutions applicable across different contexts.

These findings reinforce the need for standardized assessment instruments¹⁰,¹³,⁴³ and for concrete organizational responses to psychosocial risk factors. Beyond exposure to traumatic events, each incident adds a cumulative emotional burden⁵⁸ to individuals and their colleagues¹¹,⁵⁷, while chronic exposure may result in neurobiological changes⁵⁹ that impair memory and emotional regulation⁶⁰. This relationship reinforces the link between occupational experience and psychological distress.

These conditions require individual and collective mental health interventions⁶¹ supported by occupational structures and interpersonal care³³. Several studies mentioned critical stress management strategies⁶², like peer-support supervision⁶³, and others forms that bring about the critical need for research in these populations, such as screening, monitoring and the effectiveness of treatments⁶⁴. However, although coping strategies⁶⁵ within care networks⁶⁶ have been discussed, evidence regarding their effectiveness remain limited⁶⁷.

The included studies reported that firefighters experience an average of 26 traumatic events throughout their careers, with psychological distress described in relation to cumulative occupational exposure and incidents involving multiple casualties²¹. Few studies followed participants for more than two years, limiting understanding of symptom trajectories. This suggests that the scarcity of emotional decompression protocols—particularly after critical incidents—contributes to worsening mental health outcomes by restricting emotional expression and psychological recovery. Other studies reported cases in which the severity of psychological distress worsened over time²²-²⁵.

Psychosocial and organizational conditions, including exhausting shifts, sleep deprivation, prolonged working hours, and irregular shift patterns²¹-²²,⁴³ further intensify these outcomes.

Within this organizational context, cultures marked by functional normativity and the stigmatization of mental disorders increase vulnerability by discouraging help-seeking behaviors and reinforcing silence around psychological suffering³⁰,³³,⁵⁰,⁶⁸. Norms that valorize endurance³³ and emotional self-control foster fear of being perceived as weak, professionally inadequate, or incapable, thereby limiting access to mental health care⁵⁰ and worsening mental health outcomes, while further entrenching stigma around mental disorders⁶⁸.

Moreover, silent suffering is exacerbated by systemic barriers such as gender stereotypes. Female firefighters experience additional psychosocial stressors, including gender discrimination, moral harassment and sexual harassment.

In one context, 37% of female firefighters reported experiencing organizational harassment in the workplace¹⁰. These conditions contribute to inequitable workloads, structural barriers to career progression, mental health risks, and higher prevalence of depression (42%)⁴⁸ and PTSD (35%)¹⁰ compared to male firefighters. In addition, others factors that further contribute to psychological distress³⁰.

Another critical dimension involves sleep deprivation, which impairs cognitive, physical, and psychological domains⁴³-⁴⁴,⁶⁹. Poor sleep increases vulnerability to mood disorders⁴⁴, reduces cognitive performance by around 40%⁴³, and raises the likelihood of operational errors attributable to planning, judgment, and emotional regulation by 60% due to executive dysfunction⁴⁴ and decision-making capacity decrease⁴³. After 18–24h of wakefulness, performance may resemble a blood alcohol concentration of 0.05–0.10%⁷⁰.

Without adequate sleep regulation, the processing of traumatic memories remains incomplete⁷⁰, complicating PTSD treatment when affective regulation and neurobiological function are disrupted. This dysregulation exacerbates PTSD symptoms, depressive episodes²⁸, and mood regulation disorders⁴⁴,⁶⁹.

Finally, alcohol consumption emerges as an additional dimension of vulnerability among these professionals⁴¹,¹⁸. Alcohol misuse affects 28% of firefighters³⁹-⁴⁰, and among veterans with longer service (15–18 years), the likelihood of developing alcoholism is tripled³⁷.

Within this context, cultural norms that emphasize emotional restraint and self-reliance shape not only vulnerability but also coping behaviors among firefighters. Rather than seeking support, many professionals adopt silence as an adaptive strategy⁷¹, a response reinforced by rigid hierarchies, limited leadership support, and fear of judgment³⁰,⁵⁰.

This pattern contributes to the normalization of distress and weakens institutional responses to mental health needs. As a result, insufficient organizational support, combined with repeated trauma exposure and alcohol use⁴¹, exacerbates PTSD and is associated with comorbid conditions such as depression²⁸ and sleep impairments⁴³-⁴⁴. By valuing resilience³³ and self-restraint, institutional cultures may inadvertently promote perceptions of invulnerability⁷¹, sustaining cycles of psychological suffering and delaying access to care.

Considering the complex clinical landscape, effective PTSD management requires multidimensional interventions capable of addressing organizational, psychosocial, and cultural barriers³⁰,⁵⁰. Strict hierarchical and fear of reprisals or career consequences limit access to mental health care³⁰,⁵⁰,⁵⁶, while stigma reinforces the reluctance to seek treatment⁷² and encourages self-sacrifice⁷³.

PTSD thus reflects the interaction of organizational, psychosocial, and cultural factors. Treating emotional problems⁴¹ as individual rather than structural challenges³⁰,⁵⁰ perpetuates systemic vulnerability and underscores the urgency of institutional change within fire services.

Therefore, reducing PTSD prevalence and other psychological conditions among firefighters requires addressing variations in organizational support systems, access to mental health services, and gender dynamics within fire departments.

Contexts characterized by supportive leadership, peer support, and structured post-incident interventions tend to report lower prevalence. In contrast, environments marked by stigma, harassment, and excessive workloads show a higher PTSD prevalence.

First, the absence of standardized post-incident protocols hinders timely intervention. Structural, institutional, and operational failures contribute to persistent psychosocial risk and underreporting⁶,²¹. Consequently, PTSD may develop as a chronic condition in firefighting contexts.

International guidelines from the WHO and ILO addressing organizational strategies related to mental health awareness³,⁷⁴, help-seeking behavior, and treatment access⁷⁵ were identified among the sources referenced by the included studies.

Nevertheless, implementing international agency programs remains challenging for organizations. These guidelines advocate top-down institutional reforms to address hierarchical barriers and working conditions, alongside bottom-up initiatives to promote mental health awareness and help-seeking behaviors.

In addition to collective action aimed at identifying and addressing psychosocial risk factors³³, it is also necessary to target workplace conditions that contribute to stress, psychological distress, and dissatisfaction⁷⁴. Without systemic change, fire departments risk perpetuating cycles in which prevention occurs only after critical incidents. Therefore, the implementation of effective policies to promote firefighters’ mental health should be prioritized⁶¹.

Critical limitations

This scoping review follows the methodological framework proposed by JBI. Nevertheless, several methodological limitations must be acknowledged. First, the absence of temporal analyses prevented the establishment of causal relationships⁶,¹⁰, as only a limited number of longitudinal investigations assessed symptom progression over time⁶,¹¹,³³,⁴³,⁴⁶,⁴⁸,⁵¹,⁵³,⁵⁴. In addition, many studies relied on small or non-representative samples¹³,⁴⁸, frequently using convenience sampling³¹,⁴⁹-⁵⁰ or single-event analyses⁶,²⁶. Some investigations lacked objective diagnostic or methodological criteria²²,⁴⁶, and underreporting may have occurred due to fear of professional or institutional consequences⁵⁵.

Second, multiple sources of bias were identified across the included studies. Selection bias related to voluntary participation²⁹-³⁰,⁵⁶ and recall bias³³ may contribute to the underestimation of PTSD prevalence²³,⁴². Interviewer bias was also observed, particularly in studies that do not include assessments focused on specific traumatic exposures³⁸.

A potential health worker effect was observed, as most studies evaluated only active firefighters, excluding individuals on medical leave. This may have led to underestimation of both the true severity of PTSD within this population, as well as potential cases of psychological distress.

Other mapped methodological limitations include insufficient differentiation between exposed and unexposed groups¹³, inclusion of behavioral or personality characteristics⁸, and limited examination of sleep patterns and shift characteristics⁴⁵.

With respect to scope and coverage, few studies conducted population-based comparisons²⁵,²⁹,³⁵, restricting broader contextual interpretation. Importantly, preventive strategies - such as training programs, emotional support initiatives⁴¹, and leadership development - were rarely addressed across studies, highlighting a critical gap in the literature. Thus, future research should incorporate occupational characteristics¹²-¹³,²⁶,²⁹,³⁹,⁴⁴,⁴⁵,⁴⁷ and ensure greater diversity regarding gender, ethnicity, race, sexual orientation, and socioeconomic status²⁴,³¹,⁴²,⁴⁹.

Finally, the limitations of this scoping review include the omission of unpublished studies, language restrictions, and the limited inclusion of grey literature. The exclusive inclusion of quantitative designs may also have resulted in the loss of valuable qualitative evidence, which is essential for understanding subjective experiences and contextual dimensions of PTSD among firefighters.

Main findings

The evidence demonstrates that PTSD among firefighters represents a substantial occupational concern. Compared to other high-risk groups, PTSD prevalence in firefighters is consistently higher⁶,⁸,³¹,³⁶,⁴²,⁴⁷, and may be two to four times greater than that observed in the general population, underscoring the magnitude of occupational exposure in this profession.

To contextualize this finding epidemiological studies, such as the National Comorbidity Survey Replication by Kessler et al.⁵, have estimated the lifetime PTSD prevalence in the general population. When contrasted with other high-risk groups, this disparity becomes particularly pronounced. In this regard, Obuobi-Donkor et al.⁴ reported PTSD prevalence among firefighters exceeding that documented in military personnell8,³¹,³⁶,⁴²,⁴⁷.

Taken together, these findings indicate that firefighters experience an exceptionally high burden of PTSD. This pattern does not reflect a statistical anomaly. Rather, it represents the cumulative impact of chronic exposure to traumatic events combined with the organizational and psychosocial stressors identified in this review.

A multidimensional and interconnected pattern of psychological suffering was evident, encompassing chronic stress, psychiatric comorbidities, and adverse organizational environments. Without systemic change, the structural barriers described in the evidence are likely to perpetuate PTSD and related conditions, including neurocognitive processes that interfere with sleep regulation and emotional functioning, thereby contributing to depressive²⁸ and anxiety-related⁶⁸ symptoms. This significant pattern appears intricately linked to variations across organizational culture in fire departments.

In light of this evidence, the high PTSD prevalence justifies the urgency of implementing targeted mental health policies and interventions at firefighters. The absence of structured mental health protocols suggests that isolated or generic wellness programs are insufficient to address the complexity of occupational stressors faced by firefighters. Accordingly, there is a need to move beyond conventional wellness initiatives within fire service culture⁶,⁸,¹²,²³,³²,⁴⁹.

Instead, tailored strategies must address the specific determinants of PTSD, including organizational, psychosocial, and occupational factors. Despite the severity of symptoms, cultural barriers to help-seeking persist.

These findings emphasize the urgent need for standardized assessment tools, longitudinal research designs, organizational reforms, and comprehensive mental health interventions aligned with international initiatives⁵⁶. In this context, WHO and ILO guidelines recommend strategies focused on stigma reduction, psychological support⁷⁴, and access to treatment for affected personnel. These measures include supporting individuals on medical leave in their return to work through reciprocal care models⁷⁵, as well as ensuring continuity of emotional support from career entry through retirement.

Finally, systematic analyses comparing firefighters with others armed forces personnel may further clarify differences related to cultural and organizational contexts that influence PTSD prevalence.

Conclusions

PTSD prevalence among firefighter’s ranges from 15% to 30%. Evidence points to psychosocial and organizational factors contributing to the worsening of outcomes associated with the disorder. Cumulative exposure to traumatic events, irregular shift work, extended duty hours, and sleep deprivation further contribute to psychological burden and the development of burnout syndrome. Female firefighters are at higher risk of PTSD than their male counterparts, and one-third report experiences of sexual harassment and discrimination in the workplace.

Beyond individual exposure, institutional cultures that prioritize performance and operational readiness, alongside hierarchical management structures and persistent stigma surrounding mental disorders, emerged as significant barriers preventing firefighters experiencing psychological distress or living with PTSD from seeking help or treatment. In this context, approaches focused exclusively on individual responsibility may inadvertently reinforce stigma⁷⁶, silence psychological suffering³⁰, and shift accountability away from organizational and institutional determinants.

From an organizational perspective, peer support initiatives³¹,⁴⁹,⁵¹ and structured mental health promotion practices play significant role within fire departments⁶,³⁴. However, their effectiveness depends on integration into broader institutional strategies rather than isolated implementation.

Accordingly, the findings indicate the need to expand access to mental health care and organizational psychological support through formal institutional policies⁸,²⁹,⁴⁰ and structured mental health programs⁵⁰,⁵⁶, moving beyond individual stress management or emotional regulation interventions²³,³⁵. Also underscore the importance of public health policies addressing PTSD through prevention⁷³, diagnosis⁷⁷, and treatments⁷⁸, grounded in humanized management approaches⁶⁵.

In this regard, a preventive framework should incorporate mental health programs involving health services, public safety agencies, and civil defense sectors, since integrated actions are required to address psychosocial and organizational risk factors to which firefighters are exposed⁷⁶.

Consistent with international experiences and guidelines, management-oriented strategies supported by empowered, human-centered leadership can reduce stigma by reframing PTSD as a condition that can be prevented, minimized, and addressed. Whether through systemic interventions aimed at improving working conditions, strengthening peer and institutional support, or expanding access to mental health services, these approaches may foster safer organizational environments and promote early recognition and care for firefighters experiencing psychological distress.

Finally, future research should prioritize longitudinal designs and follow-up assessments to evaluate the effectiveness of preventive and therapeutic interventions. Individual-level care strategies, combined with improvements in working conditions and organizational environments, are essential to promote the well-being of all professionals involved in the mental health care of firefighters affected by PTSD.

Acknowledgments

The authors would like to thank Diogenes Martins Munhoz for his valuable contribution and support, which were essential to the development of this article.

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• Data availability:
  All data extracted and analyzed in this scoping review are publicly available in the Open Science Framework (OSF) repository. The dataset includes the standardized data extraction forms and aggregated variables used for descriptive synthesis and figure generation. The data can be accessed at https://doi.org/10.17605/osf.io/AJ3P4. The data is also available in a Google Drive® cloud repository as a complementary method of access and preservation. (https://drive.google.com/drive/folders/1YQYPz28sKgwQS5ZYG-yWDaGF9yGd7gib?usp=drive_link).
• Statement on the use of Artificial Intelligence:
  The authors declare that no Artificial Intelligence tools were used in the preparation of this article.
• Presentation at a scientific event:
  The authors declare that the study has not been presented at a scientific event.
• Funding:
  The authors declare that the study was subsidized by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES; processo nº 88887.988158/2024-00).

Edited by

• Responsible editor:
  Leila Posenato Garcia. https://orcid.org/0000-0003-1146-2641. Fundação Jorge Duprat Figueiredo de Segurança e Medicina do Trabalho – FUNDACENTRO

Data availability

All data extracted and analyzed in this scoping review are publicly available in the Open Science Framework (OSF) repository. The dataset includes the standardized data extraction forms and aggregated variables used for descriptive synthesis and figure generation. The data can be accessed at https://doi.org/10.17605/osf.io/AJ3P4. The data is also available in a Google Drive® cloud repository as a complementary method of access and preservation. (https://drive.google.com/drive/folders/1YQYPz28sKgwQS5ZYG-yWDaGF9yGd7gib?usp=drive_link).

Publication Dates

• Publication in this collection
  27 July 2026
• Date of issue
  2026

History

• Received
  02 Sept 2025
• Reviewed
  13 Jan 2026
• Accepted
  15 Jan 2026