Depression, Anxiety, and Traumatic Stress Symptoms among Emergency Service Workers in Finland after a Post-Critical Incident Seminar—A Pilot Study

Round 1

Reviewer 1 Report

The authors aim to evaluate exploratory if emergency workers may benefit on depression, anxiety and impact of event scales after attending a post-critical incident seminar. 

The authors should expand on the details such as content and duration of the PCIS in the intro and method section. This is the new tool and should occupy most space,relatively speaking.

To stay in the word limit, authors may shorten the description of the commonly used scales BDI BAI IES-R.

To me it is unclear what the selection criteria was to attend the PICS. A recent incident, e.g. with then past 3 month? or anything that keeps upcoming, even if longer time ago? Did the firefighters volunteered to participate in PICS? Or were they assigned? Please add to method section.

The Impact of event scale deals with symptoms in the past seven days from a specific event? Was this specific event assessed? please add.

Please quickly explain what the standard procedure was before PICS was introduced in the emergency workers-departments. Do the authors have any information how well (or not well) the previous "standard care" worked in rescue workers in Finland? You may recommend to evaluate PICS against standard care in a later trial. So far it is valid to conclude that u see changes in scores from PICS at 1 3 6 month. But technically you have no RCT, so authors should be carefully interpret there results regarding the "specific" effect of PICS. In addition, you may abstain from p-values and rather interpret effect sizes with 95%CI  and clinical relevant change (i.e. change in categories from "severe depressed" to "mild" or so.  Authors may also indicate what timepoints they find most relevant after PICS. The chances increase with (measurement) time that that a new / further incident increased the mental burden. I assume emergency workers returned to regular work schedule after the PICS, correct?

Authors show sub scales of the IES  in tab1, but I have not seen an interpretation of theses sub scales in the text. You can reduce the digits of the SD to 2 digits after the decimal point. 

Does seasonality play a role for the mental health outcomes 6 month later?

The title should indicate the study type, e.g. pilot study or exploratory study. 

Please pic the appropriate checklist from https://www.equator-network.org/

and ensure that the items from the checklist are included in the brief report (as appropriate).

Overall, its a nice brief report, well done. 

Author Response

Reviewer #1: Comments and Suggestions for Authors

The authors aim to evaluate exploratory if emergency workers may benefit on depression, anxiety and impact of event scales after attending a post-critical incident seminar. 

The authors should expand on the details such as content and duration of the PCIS in the intro and method section. This is the new tool and should occupy most space,relatively speaking.

• Thank you for highlighting the importance of explaining in more detail the structure and practicalities of PCIS. We agree and as requested, we have added several details of PCIS that we see important into the Introduction and Method sections. We hope that with these additions the whole article can be more comprehensively understood.

To stay in the word limit, authors may shorten the description of the commonly used scales BDI BAI IES-R.

• We carefully read the instructions for word limits but did not find specific limit for the brief report. We also compared our manuscript length to other brief reports in the same journal and concluded that we are still “short enough”. Therefore, we chose not to shorten these descriptions, as the information is relevant when discussing the clinical relevancy. However, this was a helpful suggestion in case of exceeding the word limits, and we thank the reviewer for the thought.

To me it is unclear what the selection criteria was to attend the PICS. A recent incident, e.g. with then past 3 month? or anything that keeps upcoming, even if longer time ago? Did the firefighters volunteered to participate in PICS? Or were they assigned? Please add to method section.

• These points are crucial, and we appreciate for bringing these up as needing more clarifications. Selection criteria was based on that there was mental burden affecting a person’s life and that the reason to apply can be a single incidents or single incidents or cumulative burden experienced. The exclusion criteria consisted of the principles that there was at least six months since the incident, there was not already an on-going long-term psychotherapy taking place and there was a foreseen benefit for a person to participate the PCIS. Participation was not ordered or assigned but fully based on voluntary will to seek support.

• We added clarifications to the Method section: “The selection criterion was the effect of the mental burden on life: the incident that happened at work and its effects were reflected on whole life or an incident that happened at private life and also affected work performance. The exclusion criteria were in principle that there was at least six months since the incident and that there was not a long-term psychotherapy already going on. In addition, it was assessed if the person could benefit from the PCIS. The participation was fully voluntary and based on the person’s will to apply. The authors of this study were not included in the selection process of the PCIS participants.”

The Impact of event scale deals with symptoms in the past seven days from a specific event? Was this specific event assessed? please add.

• Thank you for pointing out the methodological accuracy. In this study, the IES scale was not used in this type of standard setting but more as an applied tool to assess well enough the symptoms over a course of time since attending PCIS. Some participants had a specific event or specific events that made them want to join PCIS but as mentioned in the selection criteria, it was also possible to join if experiencing cumulative mental burden. However, same scale was used for everyone. The participants were not asked to indicate if they had a separate incident or incidents in mind when filling in the questionnaires. The sample size was small so this may not have been so much of scientific benefit in this study. In future studies with larger sample size this would be interesting information to include.

• In accordance with the comment, we added this sentence to the Method section: “The participants were not asked to indicate if they had experienced a single incident, single incidents or cumulative burden when filling in the questionnaires.”

Please quickly explain what the standard procedure was before PICS was introduced in the emergency workers-departments. Do the authors have any information how well (or not well) the previous "standard care" worked in rescue workers in Finland?

• Thank you for bringing this up, these issues were important to add to the manuscript. All the employees, including emergency workers, have a statutory right to multi-professional occupational health care in Finland, and it is free for the employees. The occupational health care also includes the services of an occupational health psychologist. The support and treatment offered by the occupational health service is individually planned in accordance with the Current Care Guidelines, which are national, independent, evidence-based clinical practice guidelines covering important issues related to Finnish health, medical treatment as well as prevention of diseases. This could be stated as the “standard care”. However, one's personal needs and own motivation affects whether the person seeks support and treatment from the occupational health care, and we do not have this information.

• We revised our manuscript in accordance with the comment. We added to the methods the following sentence: “In Finland, all employees have a statutory occupational health care, which is free for the employees and individually planned in accordance with the Current Care Guidelines, being the standard care. The PCIS is not part of the statutory occupational health care, instead organized by the Finnish Association of Fire Officers.” We also revised the methodological considerations in accordance and clarified that we are not drawing conclusions of “the received standard or other care prior of the PCIS”.

You may recommend to evaluate PICS against standard care in a later trial. So far it is valid to conclude that u see changes in scores from PICS at 1 3 6 month. But technically you have no RCT, so authors should be carefully interpret there results regarding the "specific" effect of PICS.

• Thank you for this suggestion, we revised our discussion in accordance with the comment. First, we added in the first paragraph of our discussion the following sentence “However, due to the absence of a control group, direct conclusions regarding the PCIS impact cannot be drawn, although a clear change was discovered.” Second, we added to the last paragraph of our discussion (before methodological considerations) the following sentence: ”In addition, the results of this study are encouraging for further studies and indicate the need for randomized controlled trial, aiming to evaluate PICS against standard care“. Third, we also revised our conclusions in accordance, now the respective sentence reads: “Future research should study the development of depression, anxiety and traumatic stress scores (also the sub-score differences and potentially variables affecting them) over longer periods among larger groups of participants and with a standard care control group.”. In addition, we made smaller revisions in our abstract and methodological considerations in accordance with the above.

In addition, you may abstain from p-values and rather interpret effect sizes with 95%CI  and clinical relevant change (i.e. change in categories from "severe depressed" to "mild" or so.  

• Thank you for this suggestion. We appreciate the idea and acknowledge that the confidence intervals would be a good way of presenting the results. We decided to use the several related samples’ non-parametric Friedman test due to its good fit for our small sample size. The Friedman test ranks the algorithms and thus, the confidence intervals cannot be calculated alongside with the test. Our strategy was to present these small sample results descriptively with mean and standard deviation for each questionnaire, and simple statistical significance calculation, allowing the reader to interpretate the results as well. We will most definitely upgrade our analysis and calculate confidence intervals when/if we are able to collect a bigger sample with good distribution measures.

• In accordance with the comment, we revised the results and discussion sections and added text regarding the clinical relevancy.

Authors may also indicate what timepoints they find most relevant after PICS. The chances increase with (measurement) time that that a new / further incident increased the mental burden. I assume emergency workers returned to regular work schedule after the PICS, correct?

• We gave this a lot of thought and concluded that there is no clear order of relevance between different timepoints. As pointed our very accurately, over time the probability of other possible incidents affecting the way participants reply may increase. However, the participants knew that filling in these questionnaires related to attending the PCIS and that may have hindered some effect of other possible incidents on the scores. Based on this, we added the following sentence into the Discussion section: “The closest timepoint to the PCIS (one month) could highlight the effects of the PCIS with the least possible effect of further possible incidents. Moreover, the furthest timepoint to the PCIS (six months) could emphasize the possible longer-term effects of the PCIS with increased possibility of further incidents affecting the scores too.” Thus, measuring the scores in different timepoints is justifiable.

• Indeed, the participants were expected to return to the regular work schedule, however the possible individual situations were beyond the focus of this study and thus not asked. We clarified to the methodological considerations the possibility of a further incident and added that “These should be taken account in the future studies.”

Authors show sub scales of the IES  in tab1, but I have not seen an interpretation of theses sub scales in the text.

• Thank you for this important consideration. We have revised the results-section in accordance with the comment and added text regarding the sub-scales also to the discussion: “Considering intrusion and avoidance aspects, as the overall traumatic stress symptoms scores, a decrease over time was found out. However, relating to hyperarousal aspect, the scores did not decrease linearly. This may be due to various reasons and this study does not provide basis for a solid interpretation. It could be assumed that hyperarousal symptoms can be more sensitive to change over time after the support received but can be decreased again due to reasons that would be needed to be studied more to define them.”

You can reduce the digits of the SD to 2 digits after the decimal point. 

• Thank you for noticing this, changed as suggested.

Does seasonality play a role for the mental health outcomes 6 month later?

• Thank you for raising this interesting aspect; if we interpreted it correct to refer to seasonal changes in the season of the year. Seasonality was not taken into consideration in this study. Due to a small sample size, clear conclusions could not be drawn on this aspect. However, this could be fascinating to keep in mind in future study settings especially due to having strong seasonal changes in a country like Finland that may affect the mood too. We clarified to the methodological considerations the possibility of a seasonality and added that “These should be taken account in the future studies.”

The title should indicate the study type, e.g. pilot study or exploratory study. 

• We added “ - a pilot study” to the title as suggested.

Please pic the appropriate checklist from https://www.equator-network.org/ and ensure that the items from the checklist are included in the brief report (as appropriate).

• We chose the STROBE checklist for cohort studies, checked the content of our manuscript in accordance with it and attached the completed document.

Overall, its a nice brief report, well done. 

• Thank you for this positive feedback and giving time to our manuscript. We feel that the comments dealt with important issues and revising the manuscript in accordance with them improved the article.

Reviewer 2 Report

This brief report is very interesting and provides useful insights for the realization of intervention. For instance, I am conducting similar studies with nurses and healthcare providers in emergency settings and I will definitely consider the insights of this study for writing my reports. I have no particular recommendations and I think the study can be published as it is. 

Author Response

Reviewer #2:

This brief report is very interesting and provides useful insights for the realization of intervention. For instance, I am conducting similar studies with nurses and healthcare providers in emergency settings and I will definitely consider the insights of this study for writing my reports. I have no particular recommendations and I think the study can be published as it is. 

• We highly appreciate these positive comments, thank you. Looking forward reading the results of the mentioned studies with nurses and healthcare providers.

Reviewer 3 Report

Thank you very much for the opportunity to read and review this report. It concerns a very important problem - it presents the longitudinal impact of PCIS on the mental health of emergency service workers who often have been exposed to critical incidents during work. We still know too little about the effects of various forms of positive interventions. Moreover, despite the small group of respondents, it is very well written and meets methodological standards. 

Congratulations to the authors!!! 

I wish them the opportunity to conduct research on the impact of PCIS on a larger group.

Author Response

Reviewer #3:

Thank you very much for the opportunity to read and review this report. It concerns a very important problem - it presents the longitudinal impact of PCIS on the mental health of emergency service workers who often have been exposed to critical incidents during work. We still know too little about the effects of various forms of positive interventions. Moreover, despite the small group of respondents, it is very well written and meets methodological standards. 

Congratulations to the authors!!! 

I wish them the opportunity to conduct research on the impact of PCIS on a larger group.

• Thank you for this positive feedback, it is highly appreciated!