Partial and full PTSD in Brazilian ambulance workers: Prevalence and impact on health and on quality...

Journal of Traumatic Stress, Vol. 20, No. 4, August 2007, pp. 637–642 ( C© 2007)

Partial and Full PTSD in Brazilian AmbulanceWorkers: Prevalence and Impact on Health and onQuality of Life

William Berger and Ivan FigueiraInstitute of Psychiatry, Universidade Federal do Rio de Janeiro (IPUB–UFRJ),Rio de Janeiro, Brazil

Ana Maria Maurat, Erika P. Bucassio, Isabela Vieira, and Sılvia R. JardimInstitute of Psychiatry, Universidade Federal do Rio de Janeiro (IPUB–UFRJ),Rio de Janeiro, Brazil

Evandro S. F. CoutinhoEscola Nacional de Saude Publica (ENSP–FIOCRUZ), Rio de Janeiro, Brazil

Jair J. MariDepartment of Psychiatry and Medical Psychology of the Sao Paulo Medical School,Universidade Federal de Sao Paulo (EPM–UNIFESP), Sao Paulo, Brazil

Mauro V. MendlowiczInstitute of Psychiatry, Universidade Federal do Rio de Janeiro (IPUB–UFRJ), Rio de Janeiro,Brazil and Department of Psychiatry and Mental Health, Universidade Federal Fluminense(MSM–UFF), Niteroi, Brazil

A cross-sectional survey for posttraumatic stress disorder (PTSD) was conducted with 234 Brazilianambulance workers (180 men and 54 women) using a sociodemographic questionnaire, the PosttraumaticStress Disorder Checklist–Civilian Version, and the Short Form Health Survey-36. Current prevalencerates for full and partial PTSD were 5.6% (men = 6.7%, women = 1.9%) and 15% (men = 13.3%,women = 20.4%), respectively. Male workers with full PTSD were more likely to be nonmarried (75%vs. 43%) and those with partial PTSD reported more emotional problems (65.2% vs. 30%) and medicalvisits (67% vs. 44%) than the controls. Workers with PTSD showed impairment in the physical andmental domains of the SF-36, whereas workers with partial PTSD had only the later compromised.The characteristics and the level of exposure to trauma of the study population may account for the lowprevalence of PTSD.

This research was supported by the grant #420122/2005-2 from the CNPq (Nacional Research Council)–Projeto Milenio–Federal Government of Brazil. Our special thanks to ColonelMarcelo D. Canetti, MD, to Lieutenant Colonel Celio Ribeiro Jr., MD, and to all the rescue workers of the GSE–CBMERJ.

Correspondence concerning this article should be addressed to: Mauro V. Mendlowicz, Department of Psychiatry and Mental Health, Universidade Federal Fluminense (MSM–UFF),Rua Tiradentes, 171 bloco 2 apartamento 903, Niteroi, RJ 24210-510, Brazil. E-mail: [email protected]

C© 2007 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20242

637

638 Berger et al.

The epidemiology of posttraumatic stress disorder

(PTSD) in ambulance workers exposed to stresses from

regular daily duty was investigated in a handful of cross-

sectional studies. Grevin (1996) employed the Posttrau-

matic Stress Disorder Scale (Keane, Weathers, & Kaloupek,

1992) to assess 120 experienced paramedics from San

Francisco Bay Area and found a current prevalence rate

of 20%. Using the Posttraumatic Stress Symptom Scale

(Foa, Riggs, Dancu, & Rothbaum, 1993), Clohessy and

Ehlers (1999) reported a prevalence of 21% in 58 am-

bulance workers from the United Kingdom. Jonsson,

Segesten, and Mattsson (2003) assessed 362 Swedish am-

bulance workers with the Impact of Event Scale (IES;

Horowitz, Wilner, & Alvarez, 1979) and found a preva-

lence of 15.2%. Bennett, Williams, Page, Hood, and

Woollard (2004) employed the Posttraumatic Diagnostic

Scale (Foa, Cashman, Jaycox, & Perry, 1997) and reported

a prevalence of 22% in 574 ambulance workers from the

United Kingdom, with women showing a significantly

higher rate than men (23% vs. 15%). In the only lon-

gitudinal study available, van der Ploeg and Kleber (2003)

used the IES to assess 123 Dutch ambulance workers and

found a prevalence rate of 13% after a one-year follow-up

period.

Posttraumatic stress disorder is known to be associ-

ated with significant adjustment problems in the pro-

fessional and family settings, with impaired physical and

mental health, and with decreased quality of life (Kessler,

Sonnega, Bromet, Hughes, & Nelson, 1995; Schonfeld

et al., 1997; Zayfert, Dums, Ferguson, & Hegel, 2002).

There is, however, evidence that individuals with partial

or subthreshold PTSD, with symptoms below the thresh-

old for the Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition (DSM-IV; American Psychiatric

Association, 1994) diagnosis, also exhibit significant im-

pairment or distress (Zlotnick, Franklin, & Zimmerman,

2002).

The aim of this study was twofold: (a) to determine the

prevalence of posttraumatic stress symptoms in a sample of

Brazilian rescue workers regularly exposed to work-related

stressful events, and (b) to compare groups with full and

partial posttraumatic stress disorder with a control group in

terms of indicators of psychosocial functioning, of physical

and mental health, and of quality of life.

M E T H O D

Participants

A cross-sectional survey was carried out between October

2003 and December 2004 with the ambulance workers

of the Group of Emergency Rescue (GSE) operating in

the city of Rio de Janeiro, Brazil. The GSE is an elite

division of the Fire Department of the State of Rio de

Janeiro that provides emergency medical assistance in the

urban areas of the state. Unlike most countries, Brazilian

Fire Departments have a paramilitary organizational struc-

ture. All GSE members hold military ranks: physicians are

commissioned officers; nurses, paramedics, and ambulance

drivers are noncommissioned officers or servicemen.

Measures

All volunteers were personally contacted by research as-

sistants in their working places and received a thorough

explanation about the objectives and methods of the study.

After signing an informed consent, they were asked to

complete three questionnaires. The first was a specifically

designed questionnaire that covered sociodemographic fea-

tures, the utilization of health services, and physical and

mental health-related information.

The second was the Posttraumatic Stress Disor-

der Checklist–Civilian Version (PCL-C; Weathers, Litz,

Herman, Huska, & Keane, 1993), a 17-item questionnaire

that evaluates posttraumatic stress symptoms according to

the DSM-IV criteria. Respondents indicate to what degree

they have been disturbed by these symptoms during the

last month, by classifying them on a 5-point scale (1 = not

at all to 5 = very much). The PCL-C score ranges from 5 to

85, with higher values implying more severe PTSD symp-

toms. The Brazilian version of PCL-C (Berger, Mendlow-

icz, Souza, & Figueira, 2004) has good internal consistency

(Cronbach’s α = .89) and test-retest reliability (r = .83,

unpublished data). The PCL-C was used to determine the

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

PTSD in Brazilian Ambulance Workers 639

presence of full PTSD according to the DSM-IV criteria,

as follows: scores equal or higher than 3 on at least 1 symp-

tom of reexperiencing (Cluster B), on at least 3 symptoms

of avoidance and numbing (Cluster C), and on at least 2

symptoms of hyperarousal (Cluster D). Partial PTSD was

considered to be present in those individuals who fulfilled

criteria for 2 out of the 3 symptom clusters (Mylle & Maes,

2002).

The third was the Short Form Health Survey-36 (SF-

36; Cicconelli, 1997), a 36-item questionnaire that assesses

eight domains of quality of life: physical functioning, role

limitations due to physical health problems, bodily pain,

social functioning, general mental health, role limitations

due to emotional problems, vitality, and general health

perceptions. The SF-36 scores range from 0 to 100, with

higher values representing more favorable states.

Data Analysis

First, prevalence rates of full and partial PTSD were es-

timated. Then, the distributions of the sociodemographic

and of the physical and mental health-related variables

were calculated for the groups with full PTSD and partial

PTSD and for those without PTSD. Two-sided chi-square

and Fisher exact tests were used for categorical variables

and two-sided Student’s t tests for the continuous ones.

To examine differences in the SF-36 scores among the

groups, a MANOVA model was constructed using the

diagnostic group as the fixed factor (full PTSD vs. partial

PTSD vs. no PTSD) and the eight SF-36 scales as the

dependent variables.

R E S U L T S

The total number of volunteers was 265. There were no

refusals to participate in the study, but 31 cases were ex-

cluded due to incompletely collected data. In a final sam-

ple comprising 234 volunteers (men = 180, women = 54),

the following prevalence figures for PTSD were found: full

PTSD = 5.6% (men = 6.7%, women = 1.9%) and partial

PTSD = 15% (men = 13.3%, women = 20.4%).

The fact that only one woman was diagnosed as having

full PTSD severely limited the possibilities of correlating

this diagnosis with other variables while controlling for

the influence of sex. Thus, it was decided to analyze only

the subsample of male ambulance workers (see Table 1).

Nevertheless, it must be noted that female workers not only

had a significantly shorter mean duration of service, 34.1

(SD = 30.6) vs. 64.7 (SD = 58.1) months, t(188) = 5.04,

p < .001, but also worked mostly as nurses, 67.2% vs.

29.5%, χ2(1, N) = 25.61, p < .001.

The comparison of the sociodemographic characteris-

tics of the three groups revealed only a trend toward a sta-

tistically significant difference in marital status. Additional

2 × 2 cross-tabulations showed that workers with full

PTSD had a significantly higher proportion of nonmar-

ried individuals than did workers without PTSD (Fisher’s

exact test, p = .04), but revealed only a trend toward sig-

nificance when the former were compared to workers with

partial PTSD (Fisher’s exact test, p = .08).

Statistically significant differences in the items “self-

reported emotional problems” and “history of medical

visits during the past 12 months” were observed. When

these differences were further explored with additional

2 × 2 cross-tabulations, it was found that workers with

partial PTSD had more frequent self-reported emotional

problems (Fisher’s exact test, p = .002) and medical visits

(Fisher’s exact test, p = .05) than workers without PTSD

symptoms.

The MANOVA showed an overall group effect on the

SF-36 scales, Hotelling’s trace = 0.18, F (16, 338) = 1.88,

p < .05. Five dependent variables showed significant

between-group differences, but post hoc Bonferroni-

corrected pairwise comparisons revealed significant effects

on only four. Individuals with full PTSD showed signif-

icantly lower scores (i.e., poorer quality of life) on the

scales that assessed role limitations due to physical health

problems, t(154) =−2.48, p < .05, role limitations due

to emotional problems, t(154) = −2.86, p = .01, vital-

ity, t(154) =−2.44, p = .05, and general mental health,

t(154) =−3.27, p < .01, than individuals without PTSD.

Workers with partial PTSD showed significantly lower

quality of life in the general mental health domain,


640 Berger et al.

Table 1. Posttraumatic Stress Symptoms in Male Ambulance Workers: Sociodemographic Characteristics, HealthStatus, and Quality of Life

No PTSD Partial PTSD Full PTSDVariables (n = 144) (n = 24) (n = 12) ValueSociodemographic and work-related characteristics

M SD M SD M SD F

Age in years 32.6 8.1 31.4 4.9 33.2 6.0 <1Duration of rescue service in months 64.7 58.8 57.9 53 83 72.2 <1

n % n % n % χ2

EducationNo college education 74 51.4 16 66.7 7 58.3 2.04At least some college 70 48.6 8 33.3 5 41.7

Marital statusNonmarried 62 43.1 9 37.5 9 75 5.12†

Married 83 56.9 15 62.5 3 25Ethnic group

Non-White 64 45.4 13 56.5 8 66.7 2.72White 77 54.6 10 43.5 4 33.3

Commissioned OfficerNo 89 65.9 20 87 8 72.7 4.15Yes 46 34.1 3 13 3 27.3

Type of workPhysician 46 34.1 3 13 25 4.12Other activities 95 65.9 21 87 75

Physical and mental health indicators

n % n % n % χ2

Self-reported physical problemsYes 11 21.1 5 26.3 7 12.5 <1No 133 78.9 14 73.7 1 87.5

Self-reported emotional problemsYes 43 30.1 15 65.2 5 45.5 11.17∗∗∗

No 100 69.9 8 34.8 6 54.5History of medical visits during the last 12 months

Yes 63 43.8 16 66.7 8 66.7 6.06∗

No 81 56.3 8 33.3 4 33.3History of hospital admissions during the last 12 months

Yes 4 5.4 0 0 1 14.3 2.07No 70 94.6 16 100 6 85.7

Short Form Health Survey-36 Scales Scores

M SD M SD M SD F

Physical functioning 91.2 15.84 86.3 16.17 82.9 17.51 2.27Role limitation due to physical health 76.4 31.37 66.7 35.86 52.1 39.11 3.69∗∗

Role limitation due to emotional problems 77.2 34.79 70.8 35.86 47.2 33.21 4.23∗∗

(Continued )


PTSD in Brazilian Ambulance Workers 641

Table 1. Continued

Short Form Health Survey-36 Scales Scores

M SD M SD M SD F

Vitality 69.6 21.23 66.0 19.67 54.3 20.03 3.11∗

General mental health 79.2 19.55 66.7 19.73 59.9 20.7 8.56∗∗∗∗

Social functioning 79.2 23.41 74 24.7 67.7 25.82 1.66Bodily pain 78.1 25.3 71.3 20.48 64.6 22.81 2.23General health perceptions 79.3 18.7 73.5 15.43 66.3 21.33 3.47∗∗

Note. PTSD = Posttraumatic stress disorder; Married = married or living together; Nonmarried = single, divorced, and widowed.Degrees of freedom equal 1 for all chi-squares presented in this table.∗ p = .05. ∗∗ p < .05. ∗∗∗ p < .005. ∗∗∗∗ p < .001. †.05 < p ≤ .10.

t(154) = −2.87, p < .05, as compared to workers with-

out PTSD.

D I S C U S S I O N

A current prevalence rate for full PTSD of 6.7% was found

in our sample of Brazilian male ambulance workers. This

figure is much lower than those that are reported in North

American and Western European studies. Although we

used a different questionnaire, we believe it is unlikely

that this alone could account for the considerable discrep-

ancy, given that the PCL-C is a widely tested screening

instrument with sound psychometric properties. Differ-

ences in the study populations and in the institutional

organization of the emergency rescue services must also be

considered. Although the samples of all previous studies

were composed exclusively by paramedics, nurses, medical

technicians and drivers, the GSE also featured a sizable

contingent of physicians (28,6%) Because low socioeco-

nomic status and lack of education are known to be risk

factors for PTSD (Brewin, Andrews, & Valentine, 2000),

it is likely that a higher socioeconomic and educational

profile of the GSE may have lowered the odds of develop-

ing PTSD. It has also been reported that highly selected

military forces with high morale involved in focused oper-

ations with positive outcomes do not exhibit the expected

deleterious psychological effects after participating in war

fighting (Hughes et al., 2005). We hypothesize that a sim-

ilar phenomenon may be at work with the rescue workers

of the GSE, an elite paramilitary force with high morale

that is thoroughly devoted to saving people in urgent need.

As Hughes and colleagues (2005) concluded about going

to war, it is conceivable that rescuing people too “does not

have to hurt.”

Another unexpected finding was the very low preva-

lence of full PTSD in female rescuers. Prevalence rates for

PTSD tend to be higher in women than in men, either

in the general population (Kessler et al., 1995) or among

ambulance workers (Bennett et al., 2004). In our study,

women not only had a significantly shorter mean duration

of service, but also worked mostly as nurses. It has been

shown that factors like the duration of the exposure and the

type of trauma involved may, in some cases, counteract the

hypothesized greater vulnerability of women to traumatic

events and even reverse these trends (Brewin et al., 2000).

Earlier research showed that PTSD impacts heavily on

both physical and mental domains of the quality of life

(Schonfeld et al., 1997). Accordingly, we found that am-

bulance workers with full PTSD had significantly lower

scores on four SF-36 scales covering distinct components

of physical and mental health than their healthy cowork-

ers. In contrast, partial PTSD seemed to be associated with

a more selective impact on the mental health domain, as

demonstrated by the facts that ambulance workers from the

partial PTSD group had lower scores on the SF-36 general

mental health scale and more frequent self-reported emo-

tional problems as compared to those without PTSD. At

this point, however, it is uncertain whether these observa-

tions should be interpreted as indicating that partial PTSD

would be better conceptualized as a discrete diagnostic


642 Berger et al.

entity that is categorically distinct from full PTSD or, al-

ternatively, as if implying that the concept of partial PTSD

represents just a conventional cut-off point in a continuum

of stress-response. Further research of the effects of trauma

on professional rescuers is needed to unravel this and other

lacunae in our current knowledge.

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