This systematic review sought to answer a critical question: What are the prevalence rates, mechanistic pathways, and effective interventions for suicide prevention among first responders, and how do these factors vary by occupation, demographic subgroup, and geographical context? The findings reveal a pervasive public health crisis, with suicide rates among first responders significantly exceeding those of the general population, driven by occupational trauma, mental health comorbidities, and systemic barriers. The synthesis of 26 studies underscores the urgency of addressing this issue through integrated, multi-level interventions that target individual vulnerabilities, organizational cultures, and policy gaps.

The first category highlights stark occupational and demographic disparities in suicidality. Firefighters report lifetime suicidal ideation rates of 46.8% [11,12,13], while EMS personnel face a tenfold higher suicide risk than civilians [14,15,16, 24]. Wildland firefighters and dispatchers also exhibit elevated risks, with 22% and 32% reporting suicide attempt histories or ideation, respectively [17, 18]. Demographic variations further underscore vulnerabilities, particularly among female firefighters [13, 19,20,21], Indigenous groups [15, 22], and retirees [23]. Trauma exposure is nearly universal, with 91.5% of firefighters [19], 94% of dispatchers [18], and 98% of EMS personnel [16] exposed to high trauma. PTSD prevalence ranges from 18.9% to 25.4% [17, 26], with symptoms strongly correlating with suicidality [13, 24, 25].

The psychological burden borne by first responders manifests through a complex interplay of mental health comorbidities and occupational stressors that collectively exacerbate suicide risk. Depression and anxiety emerge as pervasive conditions, with mean PHQ-9 and GAD-7 scores of 8.35 and 6.88 respectively [24, 26] - levels that approach or exceed clinical thresholds. The severity of this burden is underscored by findings that depression alone increases the odds of suicidal ideation nearly ninefold (OR = 8.92) [20, 27], suggesting mood disorders represent one of the most potent risk factors in this population.

Substance use disorders compound this risk through multiple pathways. Hazardous drinking affects 38.8% of first responders [26, 28], while alcohol use disorders (AUDs) serve as both a maladaptive coping mechanism for trauma and a mediator in the PTSD-suicide pathway [25, 29]. Sleep disturbances, particularly insomnia, create an additional vicious cycle by worsening PTSD symptoms while simultaneously mediating their relationship with suicidal ideation [23, 25]. This triad of depression, substance misuse, and sleep disruption forms a particularly lethal combination that demands integrated treatment approaches.

Occupational culture and conditions further amplify these psychological risks. The deeply ingrained “culture of stoicism“ [12, 24, 30] discourages emotional expression and help-seeking, while workplace bullying directly predicts suicide plans and attempts [31]. Burnout manifests as emotional exhaustion that correlates strongly with suicide risk scores (β = 0.42) [15, 16, 32], particularly among EMS personnel with repeated suicide exposure. These occupational stressors interact synergistically with psychological vulnerabilities - for instance, the combination of high PTSD symptoms and low distress tolerance markedly increases suicide risk [19].

The cumulative impact of these factors creates a perfect storm of risk that varies by occupational subgroup. Firefighters face unique risks from interpersonal factors like perceived burdensomeness [28], while EMS personnel are particularly vulnerable to burnout from repeated trauma exposure [16]. This heterogeneity underscores the need for tailored interventions that address both universal psychological vulnerabilities and occupation-specific stressors. The findings collectively highlight that suicide prevention in first responders must move beyond symptom management to transform occupational cultures and address the root causes of psychological distress.

The structural obstacles preventing effective mental health care for first responders form a complex web of institutional, cultural, and geographical barriers that perpetuate the silent crisis of responder suicidality. At their core, stigma and systematic underreporting of psychological distress remain entrenched, fueled by legitimate fears of professional consequences including perceived weakness, missed promotions, or even job loss [13, 24, 30, 33, 34]. This stigma is particularly pronounced in male-dominated emergency service cultures that valorize stoicism and equate emotional vulnerability with professional incompetence [13, 14]. The resulting “code of silence” creates a paradox where those routinely exposed to trauma are discouraged from seeking help for trauma-related disorders.

Geographical disparities in access to care present another formidable barrier. Rural first responders face particularly acute shortages of mental health services, with Employee Assistance Programs (EAPs) either nonexistent or woefully inadequate to meet demand [26, 30]. Even in urban areas, utilization remains shockingly low - a mere 27% of dispatchers report comfort discussing mental health concerns [18], suggesting systemic failures in program design and implementation rather than simple service availability. These access issues are compounded by critical shortages of clinicians trained in both trauma-informed care and the unique occupational contexts of emergency services [15, 32]. Many mental health providers lack understanding of firehouse culture, shift work challenges, or the cumulative impact of repeated trauma exposure, leading to misdiagnosis or ineffective treatment.

The training pipeline for first responders reveals another systemic shortcoming. While technical skills receive extensive instruction, mental health training remains inconsistent and often superficial [24, 30]. Most programs fail to adequately address suicide prevention, trauma coping strategies, or help-seeking behaviors. This training deficit perpetuates harmful misconceptions and leaves personnel unprepared to support colleagues in crisis.

Despite these challenges, promising solutions are emerging. Grassroots initiatives led by peer advocates within responder communities have proven particularly effective in bridging the trust gap [30]. Houston’s mandatory officer training program, achieving 85% completion rates [34], demonstrates how institutional commitment can overcome cultural resistance. However, these successes remain localized and fragile, requiring broader policy support and funding to achieve system-wide impact.

The interplay of these barriers creates a perfect storm where even available services go underutilized. Structural reforms must simultaneously address stigma through cultural change initiatives, improve geographic access through telemedicine and mobile crisis units, and mandate comprehensive mental health training for both responders and clinicians. Without such multi-pronged interventions, systemic barriers will continue to undermine even the most clinically effective treatment modalities.

The synthesis of evidence points to an urgent need for comprehensive, multilayered interventions that address the complex etiology of suicide risk among first responders. At the clinical level, trauma-focused psychotherapies demonstrate particular efficacy, with Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) showing significant reductions in both post-traumatic stress symptoms (PTSS) and suicidality [22, 29, 34]. These evidence-based approaches help responders process traumatic experiences and modify maladaptive cognitions, with effects that extend beyond symptom reduction to improve overall functioning and quality of life.

Peer-support programs emerge as a particularly promising intervention, leveraging the unique trust and understanding among colleagues to facilitate help-seeking [13, 16, 29]. These programs range from formal peer-counseling initiatives to informal “buddy systems,” all sharing the common benefit of reducing isolation while overcoming barriers posed by traditional mental health stigma. When properly implemented with adequate training and organizational support, peer networks can serve as early warning systems while fostering a culture of mutual support.

Early identification through routine mental health screenings represents another critical component of prevention [20, 22]. Regular, mandatory assessments using validated tools for PTSD, depression, and alcohol abuse [23] enable timely intervention before crises develop. Such screenings should be normalized as part of occupational health protocols, analogous to physical health examinations, with particular attention to high-risk periods following critical incidents or during career transitions.

Organizational-level strategies demonstrate that systemic change is both possible and impactful. Houston’s landmark 3-phase suicide prevention program, which achieved five consecutive years without active-duty suicides [34], provides a replicable model combining education, peer support, and leadership engagement. Similarly, means restriction policies [14]- including secure firearm storage protocols and medication monitoring - have shown particular effectiveness given the impulsive nature of many suicide attempts in this population.

Cultural transformation remains fundamental to sustainable change. Destigmatization campaigns that feature respected leaders sharing their mental health journeys [21, 22] can reshape organizational norms, while skills-based training in emotional literacy and help-seeking [13, 21] equips personnel with concrete alternatives to silence and suffering. These efforts must be reinforced through policy changes that guarantee confidentiality and protect career advancement opportunities for those seeking care.

The most effective interventions adopt an integrated approach that simultaneously addresses individual psychological needs while transforming organizational cultures. Future directions should explore technology-enhanced solutions (e.g., telehealth, mobile apps) to improve access, as well as the development of responder-specific treatment protocols that account for occupational stressors and trauma exposure patterns. Ultimately, saving those who save others requires nothing less than a fundamental reimagining of mental healthcare in emergency services - one that prioritizes prevention, honors lived experience, and makes psychological wellness as non-negotiable as physical safety.

Despite its comprehensive scope, this review has several limitations, including the predominance of cross-sectional studies, which limit causal inferences, and the overrepresentation of U.S.-based research, potentially restricting generalizability to non-Western contexts. Additionally, reliance on self-reported data may introduce bias, while the exclusion of non-English studies could overlook valuable insights from diverse populations. Future research should prioritize longitudinal designs to establish temporal relationships, expand geographic and cultural diversity to capture global variations, and incorporate mixed-methods approaches to deepen understanding of contextual factors. Investigations into the long-term efficacy of interventions, particularly in low-resource settings, are also needed to develop scalable, culturally adapted solutions.