International Journal of Disaster Risk Reduction xxx (xxxx) xxx–xxx

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International Journal of Disaster Risk Reduction

journal homepage: www.elsevier.com/locate/ijdrr

Review article

Psychological impacts of disaster on rescue workers: A review of the

literature
⁎
Xiaorong Maoa,b, Olivia Wai Man Funga, Xiuying Huc, Alice Yuen Lokea,
a
School of Nursing, the Hong Kong Polytechnic University, Hung Hum, Kowloon, Hong Kong
b
Institute for Disaster Management and Reconstruction, Sichuan University –Hong Kong Polytechnic University, Chengdu, Sichuan, China
c
School of Nursing /West China Hospital, Sichuan University, Chengdu, Sichuan, China

A R T I C L E I N F O A B S T R A C T

Keywords: When a disaster strikes, rescue workers are deployed to the disaster site to provide immediate rescue support to
Disaster rescue workers victims. Given the unpredictable and overwhelming nature of disasters, rescue workers are at risk of suffering
Psychological sequels from negative psychological consequences. The goal of this review is to explore the psychological impact of a
Acute stress disorders disaster on rescue workers. In this paper, a total of 55 articles – one qualitative study, 53 quantitative studies,
Anxiety and depression
and one mixed-methods study – were eligible for inclusion. The rescue workers identified in the literature
Post-traumatic stress disorder
included fire fighters, police officers, military personnel/soldiers, healthcare professionals, and volunteers. The
literature revealed that these rescue workers who were deployed to disaster sites might suffer from acute stress
disorder (ASD), anxiety and depression, post-traumatic stress disorder (PTSD), and other psychological dis-
orders. Generally, of all rescuers and nurses among the healthcare professionals, the unaffiliated volunteers were
most susceptible to negative psychological consequences. The findings of this review indicated that rescue
workers are at a high risk of experiencing psychological problems after a disaster deployment. Interventions are
needed to mitigate negative psychological consequences and foster resilience in rescue workers.

1. Introduction nature, rescue workers invariably encounter seriously injured or dead

A disaster is defined as “a situation or event that overwhelms local
capacity, necessitating a request at the national or international level
for external assistance; an unforeseen and often sudden event that
causes great damage, destruction and human suffering” ([1] p. 15).
With the increasing number of disasters worldwide, a large number of
people have been affected and the economic losses have been sig-
nificant [2]. Disasters have also had a harmful impact on the physical,
psychological, and sociological health of the people involved in rescue
efforts [3-6,21].
Previously published studies mainly focused on the psychological
impact of disasters on survivors. More recently, however, increasing
attention also has been paid to the rescue workers. Rescue workers, or
rescuers, refer to individuals who provide assistance to people in
emergency circumstances such as disaster [7]. In the context of this
review, we use the term of rescue workers refer to professionals such as
firefighters, police officers, military personnel/soldiers, healthcare
rescuers, and nonprofessional volunteers who free people from danger
in various disasters, provide acute medical care, and transport them to
facilities where they can receive better care [8]. Because of the work
bodies, witness the emotional reactions of devastated survivors (dis-
tress, grief, and anger), experience disappointment when they were
unsuccessful in saving a life, and exposed themselves to potential
physical harm. All these stressors could increase the likelihood of ne-
gative psychological consequences among rescuers, compared to the
general population who are not exposed to a disaster [9,10]. The ne-
gative psychological impact of disaster on rescue workers include acute
distress disorder, anxiety and depression, post-traumatic stress disorder
(PTSD), and substance use/dependency disorders [11,12].
Previous reviews of related literature were examined. There is one
review of studies exploring the mental health impact of volunteering in
disaster rescues [13]. However, only nine articles (1994–2007) were
included in this review, which focused solely on nonprofessional vo-
lunteers. Other reviews focused only on the issue of PTSD among
emergency medical service responders [14], first responders [15], or
volunteers [16] who 6responded to terrorist attacks, and did not in-
clude those exposed to natural disasters, technological disasters. These
reviews also failed to explore other types of negative psychological
sequelae, such as acute stress disorder (ASD), anxiety and depression
[17].

⁎
Corresponding author.
E-mail address: alice.yuen.loke@polyu.edu.hk (A.Y. Loke).

https://doi.org/10.1016/j.ijdrr.2017.10.020
Received 4 August 2017; Received in revised form 20 October 2017; Accepted 27 October 2017
2212-4209/ © 2017 Elsevier Ltd. All rights reserved.

Please cite this article as: Mao, X., International Journal of Disaster Risk Reduction (2017), http://dx.doi.org/10.1016/j.ijdrr.2017.10.020
X. Mao et al.
PTSD was the most common psychopathology among those who
involved in disasters [18,19], and the prevalence of PTSD among first
responders following manmade disaster ranged from 1.3% to 22.0%
[15]. However, the literature review regarding the psychological im-
pact of natural disaster on rescuers was not found. Majority of in-
dividuals who suffered from PTSD may have comorbid disorders, in-
cluding anxiety disorders, major depressive disorder, substance abuse/
dependency disorders [12]. Accordingly, a comprehensive picture of
the wide range of psychological morbidities in various types of rescuers
who have responded to all kinds of disasters is missing.
The purpose of this review study is to explore a wide range of
psychological impacts of natural or manmade/technological disasters
on rescue workers who are from different occupational backgrounds.
The findings of this comprehensive review will provide emergency and
disaster response organizations with the information that they need to
monitor the mental health of disaster rescue workers before and after
deployment.
2. Methods
2.1. Literature search strategy
Studies were searched using eight electronic databases: the ISI Web
of Science, PubMed, MEDLINE (Ovid), Embase, CINAHL, PILOTS,
PsycINFO, and the CNKI databases since their inception until November
30th, 2016. Three groups of key words or medical subject headings
(Mesh) terms were used for the search. These included: “rescue per-
sonnel*” or “emergency responder*” or “first responder*” or “rescue
worker*” or “disaster worker*” or “rescue* or ”humanitarian
2
International Journal of Disaster Risk Reduction xxx (xxxx) xxx–xxx
Fig. 1. The flow diagram on identifying the litera-
ture.
responder*” or “disaster relief worker*” or “firefighter*” or “police
officer*” or “military*” or “soldier*” or “ healthcare professional*” or
“paramedic*” or “ambulance personnel” or “volunteer*” AND disaster*
or “catastrophe* or ”emergency” or “traumatic event*” or “extreme
event*” or “critical incident*” or “earthquake*” or “flood*” or “tsu-
nami*” or “landslide*” or “hurricane*” or “avalanche*” or “fire” or
“terrorist attack*” or “terrorism” “war*” or “explosion*” AND “psy-
chological issue*” or “psychological impact*” or “psychological
trauma*” or “psychological adverse effect*” or “psychological stress*”
or “psychological disorder*” or “post-traumatic stress disorder” or
“PTSD” or “psychological negative consequence*” or “acute stress dis-
order” or “ASD” or “ anxiety “ or “depression”. In addition, a hand
search of the reference lists of the included articles was conducted to
identify additional relevant literature.
2.2. The selection process
All article citations downloaded from the databases were imported
into the Endnote software, X7 version. After duplications were re-
moved, articles were selected based on the criteria for inclusion and
exclusion. The criteria for the inclusion were articles: (i) published in
English or Chinese (languages understand by the authors); (ii) focusing
on the psychological impacts such as ASD, anxiety and/or depression,
PTSD and other psychological reactions, of any types of disasters
(natural disasters or manmade / technological disasters), (iii) focusing
on certain kinds of rescue workers (firefighters, police officers, military
personnel/soldiers, healthcare professionals, voluntary rescue workers,
rescue teams); and (iv) containing original data. The exclusion criteria
were articles: (i) focusing on the impact of the disaster on survivors,
X. Mao et al.
children/adolescents, or other victims; (ii) testing different versions of
psychological instruments; (iii) examining the effect of interventions for
disaster rescuers; (iv) repeated data in different articles; and (v) con-
sisting of reviews, commentaries, editorials, unpublished manuscripts,
and conference proceedings.
A total of 2109 articles were identified through the database search
and an additional 6 were identified from the hand search. After du-
plicated articles were removed, 790 articles were screened based on
title and abstracts, and 675 articles that did not meet the inclusion
criteria were excluded. The remaining 115 full-text articles were further
assessed for eligibility. Finally, 55 articles, including one qualitative, 53
quantitative, and one mixed-methods study were included in this re-
view. Among the 54 quantitative / mixed-methods studies, 15 were
longitudinal studies and 39 were cross-sectional studies.
The PRISMA guideline [20] was adopted for identifying and se-
lecting articles in this review (Fig. 1).
2.3. Appraisal of quality and data extraction
All included articles were appraised for quality using the critical
appraisal checklists for cross-sectional /observational epidemiological
studies [21] and qualitative studies [22]. These appraisal checklists
were developed by the Joanna Briggs Institute (JBI) and have been used
to assess the methodological quality of studies included in systematic
reviews and for creating Critically Appraised Topics (CAT) [23]. It was
considered that all of the studies met the criteria for inclusion at an
acceptable level of quality at grade B or above.
The data extracted from the included articles were summarized in a
standard table format (Table 1). The following information is pre-
sented: author, country of study, year of publication, study design, type
of disaster involved, time of assessment after the disaster work, popu-
lation and sample size, instruments used, and psychological con-
sequences. The results of the appraisal of the quality of the included
literature are also presented in the last column of the table.
3. Results
3.1. General characteristics
The 55 studies were conducted in 18 countries, with the most
conducted in the United States of America (USA, n = 22), followed by
China (n = 7), Taiwan (n = 5), and the Netherlands (n = 3). Other
studies were conducted in Japan (n = 2), Australia (n = 2), Turkey (n
= 2), Norway (n = 2), and one study from each of the countries: the
United Kingdom, Denmark, Sweden, Italy, Canada, Spain, Pakistan,
Indonesia, Iran, and Haiti.
Thirty-four of the 55 studies involved technological / manmade
disasters, including the World Trade Center (WTC) disaster of
September 11, 2001 (hereafter, 9/11) (n = 14), airplane crash/ship-
wreck (n = 6), terrorist attacks (n = 4), bombings / explosions (n = 4),
and fire disasters (n = 6). The other 20 studies involved natural dis-
asters such as earthquakes (n = 17), a hurricane (n = 2), and a tsunami
(n = 1). One is a web-based study of Federal Disaster Responders from
the National Disaster Medical System (NDMS), who were involved in
different types of disasters [24].
The sample size in the included articles ranged from 13 to 11,006,
with a total of 80,999 rescue workers. Thirty-eight studies focused so-
lely on one type of rescuer: 25,906 firefighters (11 studies), 21,025
police officers (8 studies), 3023 military personnel/soldiers (6 studies),
3918 healthcare personnel (10 studies), and 596 volunteers (3 studies).
Seventeen studies included 26,621 rescue team members from different
backgrounds comprised of mixed groups of firefighters, police officers,
emergency medical services personnel, ambulance personnel, health-
care providers, psychosocial personnel, Red Crescent workers, and vo-
lunteers.
3
International Journal of Disaster Risk Reduction xxx (xxxx) xxx–xxx
3.2. Findings
The studies that were included confirmed that after returning from a
disaster scene, some of rescue workers suffered negative psychological
consequences, including acute stress disorder (ASD, 4 studies), anxiety
and / or depression (20 studies), post-traumatic stress disorder (PTSD,
46 studies), and other disaster-related psychological symptoms (20
studies) (Table 1). Table 2 summarized the prevalence of psychological
consequences among rescue workers of different professional back-
grounds.
3.2.1. Acute stress disorder
Acute stress disorder (ASD), also called acute stress reaction, “de-
velops after exposure to one or more traumatic events such as nature
disasters and severe accidents, and characterized by symptoms of in-
trusion, negative mood, dissociation, avoidance, and arousal. These
symptoms usually appear within minutes after the stressful stimulus or
event, and must last at least three days but no more than one month”
([25], pp 280–286).
Only four of the 55 articles (7.27%) reported on ASD among rescue
personnel involved in a disaster. These four studies focused on military
personnel and members of rescue teams (fighters, police officers,
medical personnel, and search and rescue personnel). ASD was mea-
sured using the Stanford Acute Stress Questionnaire, and was reported
to affect 2.0–25.6% of rescue workers of their return from a disaster
scene [26-28].
The prevalence of rescue workers exposed to various types of dis-
asters who met the criteria for ASD varied. In one study, ASD affected
9% of military rescuers in the first two weeks after they returned from
an earthquake site, decreasing to 2–3% a month after their return [26].
The prevalence of ASD was reported to be relatively higher among
those who responded to manmade /technological disasters. Among
those who engaged in US AIR Flight 427 crashed in 1994, 5% rescuers
met the criteria for ASD at one week after the disaster [29]. Among
those exposed to the 9/11 terrorist attack on the World Trade Center in
New York City, 14.6% disaster workers were diagnosed with ASD at 2–3
weeks after the disaster [28]. In another study, 25.6% rescuers who
responded to a United Airlines DC-10 crash in 1989 met the criteria for
ASD [27].
3.2.2. Anxiety and/or depression
Anxiety refers to anticipation of a future concern other current
events. It is an emotion that were characterized by worried thoughts,
feelings of tension, and array of physical symptoms such as sweating,
trembling, dizziness, increased blood pressure, and rapid heart rate
[30,4]. Depression, also called major depressive disorder, can be di-
agnosed if symptoms, including lack of interest and energy, significant
weight gain or loss, excessive sleeping or insomnia, difficulty to con-
centrate, hopelessness, excessive guilt and recurrent thoughts of sui-
cide, continue to more than two weeks [31].
A total of 20 (36.4%) out of the 55 studies investigated the anxiety
and/or depression suffered by various types of rescue workers. They
focused on fighters (n = 3), police officers (n = 3), military personnel
(n = 1), healthcare rescue workers (n = 3), volunteers (n = 1), and
rescue teams comprised of various professionals (n = 9).
Ten studies focused on both anxiety and depression. The studies
adopted various instruments to measure anxiety and depression, in-
cluding: the Symptom Check List (SCL) [9,32,33], the Brief Symptom
Rating Scale (BSRS) [34]，the Psychological Distress Index (PDI) [35],
the Mini International Neuropsychiatric Interview (MINI) [36], the
General Health Questionnaire (GHQ) [37], the Pakistan Anxiety De-
pression Questionnaire (PADQ) [38], the Beck Depression Inventory
(BDI), the Brief Symptom Inventory (BSI) [39], the Generalized Anxiety
Disorder Scale (GAD), and the Patient Health Questionnaire (PHQ)
[24].
Ten of the 20 studies focused solely on the depression of rescue
 Table 1
Summary of the psychological impacts of disaster on rescue workers.
X. Mao et al.

Studies (authors/ Study design Type of disaster Population/ Time of Instruments used Psychological symptoms Quality
year/countries) Sample size assessmentPost- appraisal
disaster Acute Stress Anxiety & Post Traumatic Other psychological
Disorder (ASD) Depression Disorder symptoms
(PTSD)

Grieger et al., [29] Cross-sectional Airplane crash Disaster workers T1: 1 week, Stanford Acute Stress T1:5% T2:5% B
U.S.A (116) T2: 6 months Questionnaire
Yeh et al. [26] Longitud-inal Earthquake Military T1: 2 weeks, Diagnostic and Statistical T1: 9% B
personnel Manual of Mental Disorders
Taiwan (187) T2: 1 month T2: 2-3%
Fullerton et al., Longitud-inal Airplane crash Exposed disaster T1: 2 months Diagnostic and Statistical T1: Depression: T3: Required psychological B
[27] U.S.A. workers Manual of Mental Disorders; counseling: exposed disaster
(207) T2: 7 months Exposed disaster Exposed disaster Exposed disaster workers: 15.1%; unexposed
workers: 25.6% ; workers: workers: 16.7%; disaster workers: 4.0%
Unexposed T3: 13 months Beck Depression Inventory; Unexposed T2: 16.4% Unexposed disaster
disaster workers disaster workers workers: 1.9%
(421) Zung Self-Rating Depression T3: 21.7%;
Scale 2.4% Unexposed
disaster workers:
T2: 10.0%
T3: 12.6%
Biggs et al. [28] Cross-sectional 9 ⁄ 11 terrorist Disaster workers 2–3 weeks Diagnostic and Statistical 14.6% Depression: Increased tobacco use: A
U.S.A. attack (90) Manual of Mental Disorders; 25.8% 54.5%
Zung Self-Rating Depression
Scale
Liao et al. [34] Cross-sectional Earthquake Rescue workers 2 months Brief Symptom Rating Scale Anxiety: 10.8% Sleep disturbances: 9.8%; A

4
Taiwan Loneliness: 8.1%;
(836) Depression: Depressive mood: 7.9% ;
14.9% Irritability: 6.9%;
Inattentiveness: 6.7%;
Tension: 6.2%;
Lack of interest: 6.0%;
Extreme suicidal ideation:
3%;
Hostility:17.6%;
Interpersonal sensitivity:
13.3%
Morren et al. [32] Cross-sectional Fire disaster Firefighters 3 years PTSD Checklist; Symptom Anxiety: 7.6% 0.9% Fatigue: 13.9%; A
Nether-lands (317) Checklist; Diagnostic Depression: 4.7% Sleep problems: 8.5%;
Interview Schedule Required psychological
counseling: 3%
Hagh-Shenas et al. Cross-sectional Earthquake Student 3 months Civilian Mississippi Scale; Anxiety: SV: 34% A
[37] volunteers (SV
100)
Iran Red Crescent SV 7.1% RCW: 5.6%
workers
(RCW 18) General Health RCW 2.1% FF: 2.8%
Firefighters Questionnaire; FF 2.7%
(FF 36) Anxiety Sensitivity Index Depression:
SV 4.7%
RCW 2.3%
FF 1.5%
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 Table 1 (continued)

Studies (authors/ Study design Type of disaster Population/ Time of Instruments used Psychological symptoms Quality
X. Mao et al.

year/countries) Sample size assessmentPost- appraisal

disaster Acute Stress Anxiety & Post Traumatic Other psychological
Disorder (ASD) Depression Disorder symptoms
(PTSD)

Huizink et al. [33] Cross-sectional Cargo aircraft Firefighters (334) 8.5 years Self-Rating Inventory For Anxiety: Firefighters: 5.4%; Fatigue: A
Nether-lands crash Post-traumatic Stress
Diagnostic Interview
Schedule;
Police officers Order Symptom Checklist; Firefighters Police officers: 6.5% Firefighters (11.7%);
(834) 27.2%;
Checklist of Individual Police officers Police officers (19.4%);
Strengths 31.7%
Depression: Sleep disturbances:
Firefighters (47.9%);
Firefighters Police officers (48.3%)
20.1%;
Police officers
21.9%
Gabriel et al. [36] Cross-sectional Terrorist attacks Police officers 12 weeks Davidson Trauma Scale; Anxiety: 0.7% 1.3% Panic disorder: 0.7% A
Spain (153) Mini International Depressi on: 1.3%
Neuropsychiatric Interview
Jayasinghe et al. Cross-sectional 9 ⁄ 11 terrorist Disaster rescue 1 year PTSD Checklist; Beck Anxiety: 2.2% 6.8% Panic disorder: 2.4% A
[39] attack and recovery Depression Inventory;
U.S.A. workers (1040) Brief Symptom Inventory Depression: 4.6%
Bowler et al. [35] Longitud-inal 9 ⁄ 11 terrorist Police officers T1: 2–3 years PTSD Checklist; Anxiety: T1: 7.8% (Women vs. A
U.S.A. attack (2940) T2: 5–6 years Peri-Traumatic Diagnostic T1: 6.0% Men: 11.9% vs.

5
Interview Schedule; T2: 6.9% 7.2%);
Depression: T2: 16.5 (Women vs.
Men:
Tress Inventory T1: 9.0%; 19.1% vs. 16.1%)
T2: 10.5%
Van der Velden Cross-sectional Earthquake Rescue team (51) 3 months Impact Of Event Scale- SCL score IES score: 3.00 ± 3.85 Alchohol use: pre and post B
et al. [9] Revised; (Anxiety): disaster: 89.3% vs. 88.4%,
(P=0.772)
Haiti Symptom Checklist pre-disaster Smoking: pre and post
10.08 ± 0.27); disaster: 23.5% vs. 27.5%,
(P=0.506)
post-disaster Required psychological
10.4 ± 0.30) counseling pre and post
(p=0.414) disaster: 0% vs. 2%,
SCL score (P=0.317)
(Depression):
pre-disaster
16.29 ± 0.73);
post-disaster
16.1 ± 0.30)
(p=0.048)
Razik et al. [38] Cross-sectional Terrorist attacks Emergency Not mentioned Impact Of Event Scale- Anxiety: 11.0% 15% B
workers Revised;
Pakistan (125) Pakistan Anxiety and Depression:
Depression Questionnaire 16.7%
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 Table 1 (continued)

Studies (authors/ Study design Type of disaster Population/ Time of Instruments used Psychological symptoms Quality
X. Mao et al.

year/countries) Sample size assessmentPost- appraisal

disaster Acute Stress Anxiety & Post Traumatic Other psychological
Disorder (ASD) Depression Disorder symptoms
(PTSD)

Loo et al. [24] Cross-sectional Not mentioned Disaster Not mentioned PTSD Checklist; Anxiety: 25.5% 10.2% Harmful alcohol use: 4% B
U.S.A. responders (568) Generalized Anxiety Depression: 27% Alcohol dependent: 0.7%
Disorder Scale;
Patient Health
Questionnaire;
Alcohol Use Disorders
Identification Test;
Federal Diagnostic
Interview Schedule
Ursano et al. [45] Longitud-inal Explosion Volunteers (44) T1: 1 month Impact of Event Scale- Depression” T1: 11% B
U.S.A. Revised;
T2: 4 months Zung Self-Rating Depression T2: 12.5% T2: 10%
T3: 13 months Scale T3: 15.9% T3: 2%
Tak et al. [43] Cross-sectional Hurricane Katrina Firefighters (525) 13 weeks Center for Epidemiologic Depression: 27% B
U.S.A. Study-Depression scale
West et al. [42] Cross-sectional Hurricane Katrina Police officers 8 weeks PTSD Checklist; Center for Depression: 26% 19% Required psychological A
U.S.A. (912) Epidemiologic Studies counseling: 14%
Depression Scale
Chiu et al. [40] Cross-sectional 9 ⁄ 11 terrorist Firefighters 4–6 years Center for Epidemiologic Depression: 7% B
attack Studies
U.S.A. (1915) Depression Scale
Gu et al., [46] Cross-sectional Earthquake Military rescuers 6 months PTSD Checklist; Depression: 2.05% B

6
China (1024) Zung Self-Rating Depression 13.67%
Scale
Matsuoka et al. Cross-sectional Earthquake Medical 1 month Center for Epidemiologic Depression: B
[41] assistance Studies Depression Scale 21.6%
Japan workers (426)
Zhen et al. [47] Cross-sectional Earthquake Nurses (210) 1 year PTSD Checklist; Traumatic Depression: 30% Suicidal ideation: 8.6% A
China Stress Symptom Checklist 27.1% Required psychological
counseling: 4.3%
Yip et al. [44] Cross-sectional 9 ⁄ 11 terrorist Emergency 12 years PTSD Checklist; Center for Depression: 7% Alcohol use: 3% A
attack medical service Epidemiologic Studies 16.7%
(EMS) workers Depression Scale;
U.S.A. (2281) Alcohol Use Disorders
Identification Test
McFarlane et al. Longitud-inal Bushfire disaster Firefighters T1: 4 months General Health T1: 32% B
[78] Australia (469) T2: 11months Questionnaire T2: 27%
T3: 29 months T3: 30%
Epstein et al. [79] Longitud-inal Air disaster Military medical T1: 6 months Structured Clinical T1: 7.5% A
Nether-lands healthcare T2: 12 months Interview for DSM-III-R T2: 12.1%
workers (355) T3: 18 months Non-Patient Edition T3: 7.3%
Hui et al. [59] Cross-sectional Shipwreck Military rescuers 1 month PTSD Checklist 17.95% B
China (39)
North et al. [72] Cross-sectional Bombing Firefighters 34 months Diagnostic Interview 13% Panic disorder: 1%; A
U.S.A. (176) Schedule Alcohol disorder: 25%
Renck et al. [77] Cross-sectional Fire disaster Police officers 18 months Posttraumatic Symptom 5％ Fatigue: 63% B
Sweden (41) Scale; Impact Of Event Sleep problems: 46%
Scale-Revised;
General Health Drank alcohol: 5%
Questionnaire
Tucker et al. [73] Cross-sectional Bombing Individuals 2 years Diagnostic Interview 8% Increased alcohol use: 10% B
U.S.A. handling human Schedule Required psychological
remains (51) counseling: 14%
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(continued on next page)

 Table 1 (continued)

Studies (authors/ Study design Type of disaster Population/ Time of Instruments used Psychological symptoms Quality
X. Mao et al.

year/countries) Sample size assessmentPost- appraisal

disaster Acute Stress Anxiety & Post Traumatic Other psychological
Disorder (ASD) Depression Disorder symptoms
(PTSD)

Chang et al. [62] Cross-sectional Earthquake Firefighters 5 months Impact Of Event Scale- 21.4% B
Taiwan (84) Revised
Stewart et al. [76] Mixed methods Aviation disaster Volunteers 3 years Modified PTSD Symptoms 46% B
Canada (13) Scale
Guo et al. [70] Cross-sectional Earthquake Firefighters 1 month Davidson Trauma Scale Firefighters: 19.8%; A
Taiwan (167) Non-professional
Soldiers rescue workers:
(85) 31.8%
Ozen et al. [68] Cross-sectional Earthquake Civil defense, 2 months Clinician-Administered 25% Smoking: 59%; B
Turkey search and rescue International Alcohol intake: 16% (per
workers (44) Neuropsychiatric Interview; month)
Post-Traumatic Stress
Diagnostic Interview
Schedule; Order Scale
Armagan et al. Cross-sectional Tsunami Medical workers 1 month Clinician-Administered 24.2% Sleep disturbances: 33% A
[66] Turkey (36) International
Neuropsychiatric Interview;
Post-Traumatic Stress
Diagnostic Interview
Schedule;
Order Scale
Zimering et al. Cross-sectional 9 ⁄ 11 terrorist Mental health 6–8 months Clinician-Administered 6.4% B

7
[67] U.S.A. attack relief workers International
(109) Neuropsychiatric Interview;
Post-Traumatic Stress
Diagnostic Interview
Schedule;
Order Scale
Perrin et al. [50] Cross-sectional 9 ⁄ 11 terrorist Police officers 2–3 years PTSD Checklist Police officers: 8.3%; A
U.S.A. attack (3925) Firefighters:
Firefighters 17.4%;
(3232) Emergency medical
Emergency service workers:
medical services 14.1%;
(1741) Volunteer
organizations:
Volunteer 9.1%;
organization Unaffiliated
(5438) volunteers:
Unaffiliated 24.5%
volunteers (3797)
Misra et al. [74] Cross-sectional Bombings Ambulance 2 months Trauma Screening 4% Substantial stress: 13% A
U.K. service personnel Questionnaire
(341)
Berninger et al. Longitud-inal 9 ⁄ 11 terrorist Firefighters T1: 6 months PTSD Checklist T1 and T2: 15.5%; A
[52] U.S.A. attack (5656) T2: 3 years T1: 8.6%;
T2: 11.1%;
(delayed onset:
44.5%)
Zhang et al., [61] Longitud-inal Earthquake Military rescuers TI: 3 months PTSD Checklist T1: 23.8% A
China (362) T2: 12 months T2: 14.86%
T3: 16 months T3: 3.27%
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 Table 1 (continued)

Studies (authors/ Study design Type of disaster Population/ Time of Instruments used Psychological symptoms Quality
X. Mao et al.

year/countries) Sample size assessmentPost- appraisal

disaster Acute Stress Anxiety & Post Traumatic Other psychological
Disorder (ASD) Depression Disorder symptoms
(PTSD)

Soo et al. [53] Longitud-inal 9 ⁄ 11 terrorist Firefighters TI: 1 year PTSD Checklist T1: 10% A
U.S.A. attack (11006) T2: 6 years T2: 7.7%
T3: 7 years T3: 6.3%
T4: 8 years T4: 7.1%
T5: 9 years T5: 7.4%
Niles et al. [54] Cross-sectional 9 ⁄ 11 terrorist Firefighters 3–4 years PTSD Checklist 10.2% A
U.S.A. attack (5363)
Wang et al. [71] Cross-sectional Earthquake Soldiers (1056) 6 months Davidson Trauma Scale 6.5% B
China
Fushimi et al. [65] Longitud-inal Earthquake Firefighters (118) T1: Immediately Impact Of Event Scale- IES score: B
Japan T2: 2 weeks Revised (IES) T1: 5.22 ± 6.75;
T2: 2.06 ± 3.48;
T3: 1 month T3: 0.96 ± 2.07
Pietrzak et al. [55] Cross-sectional 9 ⁄ 11 terrorist Police officers 3.9 years PTSD Checklist 5.4% B
U.S.A. attack (8466)
Huang et al. [69] Cross-sectional Earthquake Rescue workers 18 months Clinician-Administered 5.96% B
China (923) International
Neuropsychiatric Interview;
Post-Traumatic Stress
Diagnostic Interview
Schedule;
Order Scale

8
Elklit et al. [75] Longitud-inal Fire disaster Rescue workers T1: 5 months Harvard Trauma T1: 1.6% B
Denmark (465) T2: 18 months Questionnaire T2: 3.1%
Pietrzak et al. [56] Longitud-inal 9 ⁄ 11 terrorist Police officers T1: 3 years PTSD Checklist (PCL) Score of PCL B
attack (4035)
U.S.A. Non-traditional T2: 6 years Police officers:
responders
(6800) T3: 8 years T1 (26.0 ± 11.2)
T2 (26.5 ± 12.2)
T3 (26.3 ± 12.5);
Non-traditional
responders:
T1
(35.2 ± 16.0)
T2 36.5 ± 17.0) T3
(36.3 ± 17.6)
Zaffina et al. [63] Longitud-inal Fire disaster Medical workers T1: immediately Clinician-Administerted T1: 30% B
Italy (30) T2: 6 months International T2: 10%
Neuropsychiatric Interview;
Post-Traumatic Stress
Diagnostic Interview
Schedule;
Order Scale;
Impact Of Event Scale-
Revised
Kang et al. [49] Cross-sectional Earthquake Medical workers 8 months PTSD Checklist 21.8% B
China (388) (Local rescuers:
28.6%; Supporting
rescuers: 18.2%;
Tibetan rescuers:
23.5%;
Han race rescuers:
International Journal of Disaster Risk Reduction xxx (xxxx) xxx–xxx

15%)
(continued on next page)
 Table 1 (continued)

Studies (authors/ Study design Type of disaster Population/ Time of Instruments used Psychological symptoms Quality
X. Mao et al.

year/countries) Sample size assessmentPost- appraisal

disaster Acute Stress Anxiety & Post Traumatic Other psychological
Disorder (ASD) Depression Disorder symptoms
(PTSD)

Cone et al. [57] Longitud-inal 9 ⁄ 11 terrorist Police officers T1: 6-7years PTSD Checklist; T1: 11.9% (women vs. A
attack (2204) men:
U.S.A. T2: 10-11 years Diagnostic And Statistical 14.9% vs. 11.5%)
Manual of Mental Disorders- T2: 11% (women vs.
IV men:
15.5% vs. 10.3%)
Skogstad et al. Cross-sectional Terrorist attack Ambulance 8–11 months PTSD Checklist Ambulance personnel: A
[51] Norway personnel (89) 4.5%;
Firefighters Firefighters: 4.1%;
(73) Police officers: 1.3 %
Police officers
(76)
Skogstad et al. Cross-sectional Terrorist attack Health care 11 months PTSD Checklist Healthcare providers: A
[60] Norway providers (858) 0.2%;
Psychosocial Psychosocial
personnel (214) personnel: 0.5%;
Police officers Police officers: 0.4%;
(253)
Firefighters Firefighters: 2%;
(102) Affiliated volunteers:
1%;
Affiliated Unaffiliated

9
volunteers (307) volunteers:
Unaffiliated 15%
volunteers (56)
Bromet et al. [58] Cross- sectional 9 ⁄ 11 terrorist Police officers 11–13 years PTSD Checklist 7.7% A
U.S.A. attack (2274)
Thormar et al. [64] Longitud-inal Earthquake Volunteers 6 months Impact Of Event Scale- T1: 28.5% A
Indonesia (449) 12 months Revised T2: 24.2%
18 months T3: 21%
Shih et al. [81] Qualitative Earthquake Nurses (46) Not mentioned Positive impacts: B
Taiwan method recognition of the
impermanence of life and
the wish to lead a more
significant life; more caring
relationships with others; a
better
appreciation of the value of
nursing and their own self-
worth.
Negative impact: fear of
earthquake disasters.
Doley et al. [80] Cross-sectional Bushfire disaster Firefighters 84 months General Health GHQ score = 1.57 ± 2.7 B
Questionnaire Psychiatric impairment:
Australia (277) (GHQ) 28% (cutoff score of GHQ
≥2.0)
International Journal of Disaster Risk Reduction xxx (xxxx) xxx–xxx
X. Mao et al. International Journal of Disaster Risk Reduction xxx (xxxx) xxx–xxx

workers. The instruments using to measure depression were the studies

Required psychological counseling: 2%-15.1%

employed the Centers for Epidemiological Studies Depression Scale
Rescue team with multi-professionals
(CESD) [40-44], the Zung Self-Rating Depression Scale (ZSRD)

Score of SCL: disaster 16.1 ± 0.30 [9]

[27,28,45,46], and the Traumatic Stress Symptom Checklist (TSSC)

Anxiety: 2.2%-25.5% [24,34,38,39]

[47].

Score of SCL: 10.4 ± 0.30 [9]

Score of SCL: 3.00 ± 3.85 [9]

3.2.2.1. Anxiety. The prevalence of anxiety was high at 27.2%, 31.7%,

Alcohol use:0.7%-88.4%
[24,27,38,39,68,69,75]
Depression : 4.6%-27%

[9,24,27,28,34,39,68]
and 25.5% among firefighters, police officers, and rescue teams,

Smoking: 23.5%-59%
Sleep problems:9.8%
Panic disorder: 2.4%

suicidal ideation:3%
[24,27,28,34,38,39] respectively. The high prevalence of firefighters (27.2%) and police
officers (31.7%) who met the criteria for anxiety at 8.5 years after the
14.6%-25.6%

1.6%-25%
rescue work were those who responded to the crash of a cargo aircraft
[27-29]

in 1992 in Holland [33]. Another study reported a high prevalence of

anxiety among rescue workers (25.5％) who had been deployed to
various disaster events at different times [24]. The lowest prevalence of
4.7% -15.9% [37,45]

[37,45,50,60,64,76]

anxiety was reported among volunteers (7.1%) [37].

Anxiety: 7.1% [37]

The three studies reported that the prevalence of anxiety among

firefighters ranged from 7.6％ to 27.2％ after deployment to disasters.
volunteers

Depression

The prevalence of anxiety among firefighters was 2.7% at 3 months

2%-46%

after the rescue work for the earthquake disaster in Iran’s Kerman
N.A

N.A

Province in 2004 [37], 7.6% at 3 years after the rescue work for the
fireworks explosion in the Netherlands in 2000 [32], and 27.2% at 8.5
Fear of earthquake disasters:

years after the rescue work for a cargo aircraft crash in 1992 [33].
Depression :16.7%-27.1%

The three studies of police officers reported that the prevalence of

Alcohol disorer:3%-10%

Required psychological

Suicidal ideation:8.6%
51,60,63,66,67,73,74]

Substantial stress:13%
counseling: 4.3%-14%

[44,47,66,73,74,819]

anxiety was 0.7％ to 31.7％ following disaster rescue work. The rela-
Healthcare workers

Sleep problems:33%

tively low prevalence of 0.7% for anxiety was for police officers at 12
weeks after being involved in the rescue work for the 2004 terrorist
[41,44,47]

[44,47,49-
0.2%-30%

attack in Madrid [36], while 6.0% and 6.9% of police officers met the
criteria for anxiety at 2–3 years and 5–6 years after exposure to the 9/
2.2%
N.A

11 terrorist attack [35], and as high a percentage as 31.7% met the

criteria for anxiety at 8.5 years after their involvement in the 1992
rescue of a cargo aircraft that had crashed in the Netherlands [33].
Militaries/soldiers

Five studies reported on the prevalence of anxiety, ranging from

[46,59,61,71,79]

2.2％ to 25.5％, among rescue teams comprised of various profes-

2.05%-23.8%

sionals. The prevalence of anxiety was reported to be 10.4% among

13.67%
2%-9%

those exposed to the 2010 earthquake in Haiti [9], 10.8% among those
[26]

[46]

N.A

exposed to the 1999 Taiwan earthquake at 2 months after the disaster

rescue [34], and 11％ to 25.5％ of rescue workers after deployment to
various kinds of disaster sites [24,38]. A lower prevalence of anxiety, at
2.2%, was observed among rescue workers engaged in rescue opera-
Required psychological ounseling:14%

tions for the 9/11 event at one year after the disaster [39].
[33,35,36,42,50,51,55,57,58,60,77]

Only one study measured the anxiety level of volunteers exposed to

The prevalence of psychological symptoms of disaster rescue workers (based on profession).

the 2004 earthquake in Bam, Iran, in which it was found that 7.1%
Score of PCL: 26.0-26.5 [56]

Sleep problems:46%-48.3%

suffered from anxiety three months after their involvement in the dis-
Depression : 1.3%-26%
Anxiety: 0.7% -31.7%

aster. None of the studies included in this review explored the pre-
Fatigue : 19.4%-63%

Panic disorder: 0.7%

Alcohol disorer:5%

valence of anxiety among military personnel and healthcare rescue

Police officers

workers.
[33,35,36,42]

[33,36,42,77]
[33,35,36]

0.4%-19%

3.2.2.2. Depression. The prevalence of depression was reported to be

N.A

high at 20.1%, 27%, 27.1%, and 27% among firefighters, police

officers, healthcare workers, and rescue teams after deployment to
Psychiatric impairment: 28%

disaster sites. A relatively lower prevalence of depression was reported

Sleeping problems: 8.5%-
IES score: 0.96-5.22 [65]
0.9%-32% [32,33,37,50-

among military rescuers (3.67%) engaged in an earthquake [46] and

Fatigue: 11.7%,-13.9%,
Depression : 4.7%-27%

Required psychological
Alcohol disorer:25%,
Anxiety : 7.6% -27%

volunteers (15.9%) in response to an explosion disaster [45].

54,60,62,70,72,78]

Panic disorder:1%;
[32,33,37,40,43]
Rescue workers

Five studies that focused on firefighters reported a prevalence of

counseling : 3%

[32,33,72,80]

depression ranging from 4.7％ to 27％ after deployment to disaster

firefighters

[32,33,37]

sites. The prevalence of depression among firefighters was reported to

47.9%

be 27% at 6 months after hurricane Katrina [43], 4.7% at 3 years after

N.A

responding to the fireworks explosion in the Netherlands that occurred

in 2000 [32], 7% at 4–6 years after the 9/11 terrorist attack [40], and
Psychological symptoms

Anxiety and depression

Acute distress disorder

20.1% at 8.5 years after the 1992 cargo aircraft crash in the Nether-
Other psychological
disorder (PTSD)
Posttraumatic stress

lands [33]. A relatively lower rate of depression was reported among

firefighters (1.5%) 3 months after the 2004 earthquake in Bam, Iran
symptoms

[37].
(ASD)

Only one study reported that as lower as 3.67% military rescuers

Table 2

responded to the 2008 Wenchuan earthquake in China met the diag-

nostic criteria for depression at 6 months after the disaster [46].

10
X. Mao et al.
There are four studies that focused on police officers, with the
prevalence of depression reported to range from 1.3% to 26%. The
percentage of police officers who met the criteria for depression was
reported to be 1.3% among those involved in the 2004 terrorist attack
in Madrid 12 weeks after the disaster [36]. A longitudinal study re-
ported that the incidence of depression among police officers rose from
9.0% at 2–3 years after the 9/11 terrorist attack to 10.5% at 5–6 years
after the attack [35]. At 8.5 years after an aircraft crash incident, 21.9%
of police officers were diagnosed with depression [33]. The highest
prevalence of depression was reported among the police officers (26%)
at 8 weeks after they responded to Hurricane Katrina in August 2005
[42].
Three studies that focused on healthcare professional rescue
workers reported that the prevalence of depression ranged from 16.7％
to 27.1％. One month after the 2011 Tōhoku earthquake in Japan,
21.6% of medical assistants experienced symptoms of depression [41].
At twelve years after the 9/11 terrorist attack, 16.7% of emergency
medical service (EMS) workers were still suffering from symptoms of
depression [44]. A study conducted one year after the 2008 Wenchuan
earthquake in China revealed that 27.1% of nurses involved suffered
from depression [47].
Only two studies reported on the prevalence of depression among
volunteers, which ranged from 4.7％ to 15.9％. The rate of depression
among volunteers increased from 12.5% at 4 months to 15.9% at 13
months after an explosion in the north of Puerto Rico in 1989 [45].
Among the student volunteers who were involved in the 2004 Bam
earthquake, 4.7% met the diagnostic criteria for depression, a higher
rate than that seen in Red Crescent Workers (2.3%) [37].
Seven studies showed the prevalence of depression among rescue
teams with professionals of various kinds, ranging from 4.6％ to 27％.
At two months after deployment to the 1999 Taiwan earthquake, 14.9%
had depression [34]. A study reported that 25.8% of rescue team
members met the criteria for depression at 2–3 weeks after responding
to the 9/11 terrorist attack [28]. Another study reported that at one
year after the 9/11 event, 4.6％ of rescuers were reported to suffer from
depression [39]. Another study revealed that the prevalence of de-
pression among rescue workers exposed to an airplane crash rose from
16.4% at 7 months to 21.7% at 13 months after the disaster [27]. Two
other studies revealed that 16.7％ and 27％ of rescue workers experi-
enced depression after providing a rescue service for victims of different
disasters [24,38]. A study reported a significant difference in the scores
for depression in the Symptom Check List among rescue workers before
and after their exposure to the 2010 Haiti earthquake (m ± sd =
16.29 ± 0.73 vs. 16.1 ± 0.30, p = 0.048) [9].
In sum, the prevalence of anxiety and depression in rescue workers
after being deployed in rescue work ranged from 0.7% to 31.7% and
1.3–27.1%, respectively [33,36,47]. The highest prevalence of anxiety
and depression was reported in a study on respondents to a cargo plane
crash [33], while the lowest prevalence was reported on respondents to
a terrorist attack [36]. Only one of the 20 studies focused specifically on
nurses; it reported the highest prevalence of depression, at 27.1%, after
deployment to earthquake rescue work.
3.2.3. Post-traumatic stress disorder
Post-traumatic stress disorder PTSD develops in some people after
exposed to extremely traumatic events such as combat, crime, and
natural disaster. It should be diagnosed if symptoms, including re-
current and intrusive memories ("flashbacks"), nightmares, persistent
avoidance and a sense of "numbness", negative emotional state, de-
tachment from other people, hyper-arousal and hyper-vigilance, and
sleep disturbances, last more than one month [48].
The majority of the studies that were included (n = 46, 83.6％)
explored PTSD among rescue workers who responded to a disaster,
including firefighters (n = 8), police officers (n = 8), military per-
sonnel / soldiers (n = 5), healthcare professionals (n = 8), volunteers
(n = 3), and members of rescue teams (n = 14) composed of rescue
11
International Journal of Disaster Risk Reduction xxx (xxxx) xxx–xxx
workers of different occupations.
In these studies, PTSD was measured using a wide variety of in-
struments. The PTSD Checklist-Civilian Version (PCL-C) was adopted in
21 studies [24,32,35,39,42,44,46,47,49-61]. The Impact of Event Scale-
Revised (IES) was adopted in seven studies [9,38,45,62-65]. The Clin-
ician-Administered Post-Traumatic Stress Disorder Scale (CAPS) was
adopted in five studies [63,66-69]. The Davidson Trauma Scale (DTS)
was adopted in three studies [36,70,71]. The Diagnostic Interview
Schedule (DIS) was adopted in two studies [72,73]. The other eight
studies adopted the Trauma Screening Questionnaire (TSQ) [74], the
Harvard Trauma Questionnaire (HTQ) [75], the Modified PTSD
Symptoms Scale (MPSS) [76], the Post-traumatic Symptom Scale
(PTSS) [77], the Diagnostic and Statistical Manual of Mental Disorders
4th Edition (DSM PTSD-IV) Scale [27], the Civilian Mississippi Scale
(CMS) [37], the General Health Questionnaire (GHQ) [78], and the
Self-Rating Inventory for Post-traumatic Stress Disorder (SRIP) [33].
The prevalence of PTSD was reported to be high at 32.0%, 19.0%,
23.8%, 30%, 46%, and 25% among firefighters, police officers, military
personnel, healthcare workers, volunteers, and rescue team members
after deployment to disaster relief. The prevalence of PTSD appears to
be lower among police officers (19.0%) in a hurricane disaster [42],
and highest among volunteers (46%) in an aviation disaster [76].
The 14 studies that focused on firefighters showed that the pre-
valence of PTSD ranged from 0.9% to 32%. The lowest prevalence of
PTSD was reported in a study of firefighters (0.9%) who were involved
in the Enschede firework explosion at three years after returning from
the disaster scene [32]. The highest prevalence of PTSD among fire-
fighters (32%) was reported among those who responded to a bushfire
at four months after the disaster [78].
Four studies attempted to explore the effect of time on the pre-
valence or levels of PTSD among firefighters. In a longitudinal study,
the rates of PTSD among firefighters who responded to a bushfire were:
32％, 27%, and 30% at 4, 11, and 29 months, respectively [78]. An-
other longitudinal study among those who responded to the 9/11 ter-
rorist attack reported rates of 10%, 7.7%, 6.3%, 7.1%, and 7.4% at 1, 6,
7, 8, and 9 years, respectively [53]. While the effects of time on the
prevalence of PTSD were not evident in these two studies, a long-
itudinal study testified that the prevalence of PTSD among firefighters
deployed to the 9/11 disaster rose from 8.6％ to 11.1% from 6 months
to 3 years, and the projected delayed onset was 44.5% after the cata-
strophe [52]. However, the PTSD scores measured by the Impact of
Event Scale (IES) among firefighters exposed to the 2011 Tōhoku
earthquake decreased over time from 5.22 ± 6.75 immediately after
disaster to 2.06 ± 3.48 at 2 weeks, and then further decreased to
0.96 ± 2.07 at 1 month in another longitudinal study [65].
Twelve studies reported on the prevalence of PTSD among police
officers, which ranged from 0.4% to 19%. PTSD affected police officers
shortly after their deployment to engage in rescue work during the
devastation of Hurricane Katrina (19% at 8 weeks) [36,42], and during
a terrorist attack (1.3% at 12 weeks) [36]. Rescue work affected those
deployed to a 1998 fire disaster in Sweden, with 5% of the police of-
ficers meeting the criteria for PTSD at 18 months afterwards [77], while
5.4% met the criteria for PTSD at 3.9 years after the 9/11 event [55].
Another study reported that 7.7% of police officers still had PTSD even
as long as 11–13 years after the 9/11 event [58].
Three longitudinal studies explored the effect of time on PTSD
among police officers. In a longitudinal study among police officers
who responded to the 9/11 event, the prevalence of PTSD increased
from 2 to 3 years to 5–6 years after deployment for both male (7.2%
and 16.1%) and female (11.9% and 19.1%) police officers [35]. An-
other study, also on police officers who responded to 9/11 incident,
reported that at 6–7 years to 10–11 years, the prevalence of PTSD re-
mained at 11.5% and 10.3% for male police officers and 14.9% and
15.5% for female police officers [57]. The scores on the PTSD Checklist
(PCL) for police officers involved in the 9/11 terrorist attack remained
relatively unchanged over time: 26 ± 11.2 (at 2 years), 26.5 ± 12.2 (at
X. Mao et al.
6 years), and 26.3 ± 12.5 (at 8 years) [56]. These studies revealed that
PTSD does not seem to improve with time.
Five studies explored the prevalence of PTSD among military per-
sonnel/soldiers and found that they ranged from 2.05% to 23.80%.
Four studies were conducted in China. In one cross-sectional study,
17.95% of military rescuers were reported to have met the criteria for
PTSD at 1 month after involvement in the 1999 shipwreck in Yantai
City [59], while other two cross-sectional studies found that 2.05–6.5%
soldiers exposed to the 2008 Wenchuan earthquake were diagnosed
with PTSD at six months after the disaster [71]. In a longitudinal study,
the prevalence of PTSD among military rescuers who responded to
2008 earthquake decreased from 23.8% at three months to 14.86% at
12 months and 3.27% at 18 months after the disaster [61]. However,
the other longitudinal study conducted in the Netherlands, showed the
increasing prevalence of PTSD among military personnel after 1988 air
crash, from 7.5% at 6 months to 12.1% at 12 months, and to 7.3% at 18
months [79].
Ten studies reported that the prevalence of PTSD ranged from 0.2%
to 30% among healthcare professionals who responded to disasters. A
study reported that 24.2% of medical rescue workers exposed to the
2004 Indian Ocean tsunami suffered from PTSD at one month after the
disaster [66]. Another study reported that 28.6% of medical rescue
workers who responded to the Yushu earthquake in China suffered from
PTSD at eight months after the disaster [49]. Nurses were reported to
have the highest prevalence of PTSD (30%) among healthcare profes-
sionals who suffered from PTSD after being deployed to the 2008
Wenchuan earthquake [47].
Ambulance service personnel had a relatively lower prevalence of
PTSD among all health professionals, at 4％ at two months after the
2005 London bombing [74], and 4.5％ at 8–11 months after a terrorist
attack [51]. However, another study reported that 7% of emergency
medical workers still suffered from PTSD even after 12 years following
their involvement in the 9/11 event [44].
Six studies reported that 2–46% of disaster rescue volunteers suf-
fered from PTSD. A study reported that nearly half (46%) of the vo-
lunteers exposed to the 1998 Swissair Flight 111 crash met the criteria
for PTSD at 3 years after the calamity [76]. Three studies compared the
prevalence of PTSD among rescue team members and noted that
15–34% of volunteers compared to 0.2–17.4% of professional rescue
workers suffered from PTSD [37,50,60]. A longitudinal study of vo-
lunteers exposed to a 1989 explosion in Puerto Rico reported a trend of
decrease in PTSD over time, with 11% at one month, 10% at four
months, and 2% at 13 months after the disaster [45]. Another study also
showed a trend of decrease in PTSD over time among volunteers re-
sponded to the 2006 Yogyakarta earthquake, with 28.5% at 6 months,
24.2% at 12 months, and 21% at 18 months [64].
Eight studies reported on the prevalence of PTSD, which ranged
from 1.6% to 25% among members of rescue teams comprised of var-
ious professional rescue workers. The studies explored the prevalence of
PTSD in rescue teams that responded to different disasters at different
times. Twenty-five percent of rescue workers met the criteria for PTSD
at 2 months after the 2003 earthquake in Turkey [68], 6.8％ at 1 year
after the 9/11 terrorist attack [39], 16.7% at 13 months after an air-
plane crash [27], and 5.96% at 18 months after the 2008 Wenchuan
earthquake [69]. Two other studies reported a PTSD prevalence of 10%
and 15% among members of rescue teams after they responded to
various types of disasters, but did not mention the amount of time that
had elapsed after the deployment [24,38]. Only one study explored the
effect of time on PTSD among members of a rescue team. It found that
the PTSD prevalence among rescuers exposed the explosion of a fire-
works factory in Denmark in 2004 increased from 1.6% at 5 months to
3.1% at 18 months after their deployment [75].
In summary, there is a broad range in the prevalence of PTSD among
rescue workers following disasters, ranging from 0.4％ [60] to 46％
[76]. Time, or the type of disaster, had no conclusive effects on the
prevalence of PTSD. Firefighters (32%), nurses (30%), and unaffiliated
12
International Journal of Disaster Risk Reduction xxx (xxxx) xxx–xxx
volunteers (46%) were more vulnerable to PTSD than other rescuers.
3.2.4. Other disaster-related psychological symptoms
A total of 20 (39.2%) articles examed other disaster-related psy-
chological symptoms or disturbed behaviors among firefighter (n = 4),
police officers (n = 4), healthcare rescuers (n = 6), rescue team
members (n = 7). The majority of the studies focused on alcohol/to-
bacco use (n = 7), sleep problems (n = 6), the need for psychological
counseling (n = 6), compassion fatigue (n = 3), panic disorder (n = 3),
and suicidal ideation (n = 2).
There were four studies that investigated disaster-related psycho-
logical symptoms among firefighter-rescuers after deployment. It was
found that firefighters suffered from compassion fatigue (11.7–13.9%)
and sleep problems (8.5–47.9%), and required psychological counseling
(3%) [32,33]. Other more severe symptoms included panic disorder
(1%) and alcohol addictive disorder (25％) at 34 months after the
Oklahoma City bombing [72], and symptoms of psychiatric impairment
(28%) at 84 months after the 1983 Australia bushfire disaster [80].
Four studies focused on disaster-related psychological symptoms
among police officers. Following Hurricane Katrina in 2005, 14％ of the
police officers who were involved in the rescue work required psy-
chological counseling at 8 weeks after the disaster [42]. In a study of
police officers who were exposed to a fire disaster in a city in central
Sweden in 1999, proportions as high as 63% and 46% experienced
symptoms of compassion fatigue and sleep problems respectively at 18
months after the disaster [77]. A study conducted 8.5 years after the
1992 Amsterdam cargo aircraft crash revealed that the police officers
involved suffered from compassion fatigue and sleep problems at rates
of 19.4% and 48.3% respectively due to the deployment [33]. By
comparison, it was reported that only 0.7% of police officers exposed to
the 2004 terrorist attacks in Madrid suffered from panic disorder [36].
There were six studies that explored disaster-related psychological
distress symptoms among healthcare rescue workers. Sleep dis-
turbances were found among 33% of medical workers at 1 month after
the tsunami [66,81]. At two months after the 2005 London bombing,
13% of ambulance service personnel were experiencing substantial
symptoms of distress [74]. At 1 year following the 2008 Wenchuan
earthquake in China, 8.6% of nurses had suicidal ideation and 4.3%
required psychological counseling [47]. At two years after the 1997
terrorist incident in Oklahoma City, among the individuals who han-
dled the human remains, 10% required psychological counseling [73].
At 12 years after the 9/11 incident, alcohol abuse was identified among
3% of emergency medical service workers [44].
Seven studies focused on disaster-related psychological distress
symptoms among rescue team members. It was discovered that 9.8% of
rescue workers experienced extreme sleep disturbances at 2 months
after the 1999 Taiwan earthquake [34]. Over half of the rescue mem-
bers (54.%%) admitted that they had increased their use of tobacco at
2–3 weeks after responding to the 9/11 event [28]. Another study also
reported that 59% and 16% of rescuers increased their cigarette
smoking and alcohol intake respectively within 2 months after the 2003
Bingol earthquake in Turkey [68]. A study of federal disaster re-
sponders reveled that 4.9% of them had engaged in harmful alcohol
consumption and 0.7% were regarded as alcohol dependent [24]. The
more severe forms of psychological distress were panic disorder (2.4%)
at 1 year after responding to the 9/11 terrorist attack [39], suicidal
ideation (3%) at 2 months after the 1999 Taiwan earthquake [34], and
the need to undergo psychological counseling (15.1%) at 13 months
after exposure to the United Airlines DC-10 plane crash [27].
In summary, common symptoms of psychological distress of res-
cuers after disaster rescue deployment were sleep problems
(9.8–48.3%), alcohol use (0.7–88.4%), panic disorders (2.4%), suicidal
ideation (3%), and the need to undergo psychological counseling
(2–15.1%).
X. Mao et al.
4. Discussion
A total of 55 articles were included in the present review to explore
the range of psychological effects on rescue workers from different
occupational background who responded to natural and manmade/
technological disasters.
Only a small number of studies attempted to explore the prevalence
of ASD among disaster rescuers. While it is understood that symptoms
of ASD are detectable within a relatively short period and usually dis-
appear soon [26], it has also been reported that rescue workers with
ASD were 7.3 times more likely to subsequently develop PTSD [27]. A
study has revealed that early interventions for those who suffer from
ASD can prevent them from developing PTSD or decrease their risk of
doing so [82]. In this vein, it is important to monitor rescue workers in
the early months after their deployment to disaster rescue sites and to
provide them with support if ASD is detected.
This review of literature has showed that the prevalence of PTSD
after deployed to disasters varied among rescue workers from different
occupations. This is postulated to be related to the process of selection,
preparedness before deployment, and the role the rescue workers
played at the disaster site [83]. It has been reported that police officers
were relatively less likely to suffer from PTSD when compared to other
rescue workers [8]. It is postulated that self- selection make police of-
ficers resilient when individuals choosing police as their career [84],
and it has been reported that higher levels of resilience, positive world
assumptions, and better social adjustment among police officers were
associated fewer PTSD symptoms [85-87]. At the same time, Police
officers undergo a stringent employment selection process and arduous
training and are well prepared to handle chaotic situations [50].
Moreover, police departments commonly offer mental support and
stress management services for officers after completing their routine
mission [35,57]. This finding highlights the importance of enhancing
resilience for rescue workers before and after deployment to prevent or
alleviate the symptoms of negative psychological effects.
This review found that high percentages of healthcare professionals,
including nurses, suffered from negative psychological effects after
deployment to disaster areas [47,66]. Because of the nature of their
professional roles, healthcare rescue workers deployed to engage in
disaster rescue efforts had to deal with a large number of seriously
injured victims all at one time/site, dead bodies, and emotionally dis-
tressed or aggressive victims and survivors, contributing to the devel-
opment of negative psychological consequences and PTSD [9,72]. In
disaster rescue, medical personnel may engage in rescue tasks without
the support of sophisticated equipment that found in hospitals, practice
in areas beyond their role and scope of training, including putting out
fires or rescuing victims from disaster sites, and find themselves in
danger zones [47,50], all of which may give rise to psychological
problems. A study has argued that resilience should be nurtured among
healthcare workers, to help them to cope with stressful environments
and demands positively, and as a strategy to prevent PTSD [88]. It has
also been shown that those who possess the traits of leadership with
heightened sense of control, would have lower level of stress [89,90].
Therefore, traits of leadership could protect healthcare professionals
from negative psychological consequences.
It is apparent that a higher rate of PTSD was identified in volunteers
(nonprofessionals) than in professional rescue workers [13]. This dif-
ference may be explained by the fact that the volunteers usually lack
preparation and special training in disaster rescue [27,70]. It can also
be related to the low degree of role clarity during their involvement in
disaster scenes [91]. As role clarity has been associated with a feeling of
control and a sense of the contribution of one’s work to the disaster
effort, which could boost their resilience to psychological distress [92].
Resilience has been viewed as dynamic but not fixed process [93], and
it involves behaviors, thoughts and actions that can be enhanced by
training, resulting in improved psychological outcomes [94]. Accord-
ingly, a stringent selection process and training programs should be in
13
International Journal of Disaster Risk Reduction xxx (xxxx) xxx–xxx
place for recruitment and deployment to prepare volunteers who are
adapted to rescue activities with resilience and to alleviate the negative
psychological consequences that they might experience
The present review shows that rescue workers involved in different
types of disaster suffered a different degree of psychological con-
sequences. Those who engaged in manmade / technological disasters
were relatively more likely to suffered from anxiety (1.5–25.5% vs.
0.7–31.7%), depression 14.9–27.1% vs. 1.3–25.8%), and PTSD
(2.8–34% vs. 0.2–46%), compared with rescue workers deployed to
natural disaster site [24,28,33,34,36,37,47,60,76]. These findings are
consistent with previous systematic review suggested that prevalence of
PTSD in the aftermath of natural disasters was lower than that after
human-made or technological disasters [95]. It may be explained by the
fact that people considered that human-caused disasters could be
avoidable/preventable and more upsetting than natural disasters [96],
which lead to more extreme negative psychological reactions. However,
it is premature to draw a conclusion that manmade / technological
disasters have more serious psychological impacts on rescue workers
since the time of outcome measures of these studies varies, the proxi-
mity to disaster site involved in rescue works, and support that one may
have received all may affect the levels of psychological reactions.
Because disasters are unpredictable, the majority of these studies
were cross-sectional observation studies [34]. Therefore, it would be
difficult, if not impossible, to come to conclusions on the causes and
effects of exposure to disasters and the adverse psychological con-
sequences in rescuers.
4.1. Limitations
There are limitations to this review. Only articles published in
English and Chinese were included in this study. Useful information and
study results published in other languages could therefore have been
missed. In this review, only manuscripts of acceptable quality based on
the appraisal quality checklist of JBI (grade B and above) were in-
cluded, while unpublished literature, editorials, conference abstracts,
and theses/ dissertations on this and related topics were excluded, in-
evitably contributing to publication bias. The included studies cover
different types of rescuers who were exposed to various types of dis-
asters, and their psychological outcomes were measured at different
time points using a variety of psychological instruments, making it
difficult to conduct a meta-analysis. In this review, the psychological
outcomes were only described in terms of range, as specific rates could
not be calculated.
4.2. Recommendations
Based on the findings of the articles included in this review, the
following recommendations are made for emergency and disaster re-
sponse organizations and on directions for future research.
4.2.1. Recommendations for emergency and disaster response organizations
It can be concluded from the results of this review that PTSD and
other negative psychological sequelae were common among rescue
workers after deployment to disaster sites. Psychological sequelae can
affect individuals over the years, and some may even emerge later if it
was not properly managed. It was also shown that police officers, who
have gone through a stringent employment selection process and
training programs, were less likely to suffer from PTSD than other
professional rescue workers and volunteers. Volunteers, who lack
training before performing rescue work and who have no access to
support from organizations after deployment, were more susceptible to
negative psychological consequences.
It is therefore paramount for emergency and disaster response or-
ganizations to identify the characteristics and skills that would be
needed in their rescue team members, and to devise appropriate se-
lection criteria. After recruitment, special training programs including
X. Mao et al.
those teaching special skills, such as cardiopulmonary resuscitation
(CPR), psychological first aid (PFA), coping skills, and mental pre-
paration, should be provided to rescuers before they are deployed to
disaster sites. It is also recommended that emergency organizations
offer appropriate psychological support, intervention, and follow-up
after rescue operations for those in need.
4.2.2. Recommendations for future research
Rescue workers are inevitably at a high risk of experiencing psy-
chological symptoms after deployment; however, they do not necessa-
rily have to suffer from adverse psychological sequelae. Individual
“resilience” was found to be negatively associated with psychological
distress in rescue workers (r = −0.203, p < 0.01) [97]. Police officers
who had a high level of resilience were actually reported to have the
ability to mitigate or reduce the negative consequences of post-trau-
matic disorders following Hurricane Katrina [87]. Individuals with
higher resilience were reported to be less likely to develop PTSD, de-
pression, and other psychological disorders, or disturbed behaviors,
such as alcohol consumption, after deployment to disaster areas
[98,99]. It has also been reported that resilience may even increase
work engagement, characterized by vigor, dedication, and absorption
among healthcare professionals, as was the case following the Tōhoku
earthquake in Japan [100].
Despite the great body of theoretical studies on resilience [101-
104], resilience remains a vague concept. There is no consensus on its
meaning or definition, particularly in the area of disaster management.
A consensus on the concept of disaster resilience remains elusive in
disaster research and scholarship [103,105]. Further studies need to be
conducted to obtain an in-depth and comprehensive understanding of
the characteristics of disaster resilience before interventions can be
developed to enhance the resistance of rescue workers.
5. Conclusions
The findings of this review showed that rescue workers are at high
risk of experiencing psychological symptoms after deployment.
Interventions are needed to mitigate negative psychological con-
sequences and to foster resilience in rescue workers. This finding
highlights the importance of stringently selecting rescue workers and
providing them with rigorous training before deployment, as well as
providing appropriate psychological support after deployment to rescue
work to prevent the development of negative psychological con-
sequences.
Funding statement
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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