Occupational exposure and post-traumatic stress disorder: A rapid review

Abstract

BACKGROUND:

Post-Traumatic Stress Disorder (PTSD) can result from occupational exposures and poses a considerable burden to workers, their families, workplaces and to society in general.

OBJECTIVE:

Our objective was to conduct a rapid review of the literature to answer the question: “Which occupations have exposures that may lead to a PTSD diagnosis?”

METHODS:

A rapid review was conducted in six steps: review question development, literature search, study selection (inclusion/exclusion), study characterization, data extraction, and data synthesis.

RESULTS:

The search identified 3428 unique references which were reviewed to find 16 relevant studies in 23 articles. The articles revealed associations between PTSD and rescue workers (police, firefighters, etc.), health care professionals, transit drivers, and bank employees which seem well supported by the literature. Some studies also suggest potential associations with PTSD and construction and extraction, electricians, manufacturing, installation, maintenance and repair, transportation and material moving, and clerical workers.

CONCLUSIONS:

A rapid review of the peer-reviewed scientific literature of PTSD prevalence or treatment suggests many occupations have exposures that could be associated with PTSD. Occupational traumatic events were most often associated with PTSD diagnosis. More research is needed to better understand the association between occupation and PTSD.

Keywords

Mental health workers’ compensation disability prevention

1 Introduction

Post-traumatic Stress Disorder (PTSD) as a result of an occupational exposure, poses a considerable burden to workers, their families, workplaces and to society in general [1]. Furthermore, individuals diagnosed with PTSD are more likely to report physical illnesses, additional mental disorders, suicide attempts, poor quality of life, and short and long-term disability than individuals without this diagnosis [2, 3]. Considering occupational exposures (exposure to traumatic situations that arise in the course of work) is important as PTSD has been associated with reduced work performance and productivity as shown through increased work loss and cutback days, reduced ability to manage job demands, and failure to return to work (RTW) after exposure [4 –8]. While the prevalence and economic impact of PTSD in Canada has not yet been fully measured, Wilson et al. [9] in their 2016 (pg 30) review posited that, “as many as 2.5 million adult Canadians and 70,000 first responders have suffered from PTSD in their lifetimes.”

One element of the burden of PTSD is reflected in the worker’s compensation costs. As of 2010, Lippel and Sikka found that workers’ compensation boards (WCBs) in Canada generally acknowledge the right to compensation for mental health problems attributable to psychological traumatic work stressors [10]. However, compensation systems are not consistently managing mental health claims from workers [11, 12]. Research examining the association between occupational exposures and PTSD diagnosis is useful to better understand how to prevent PTSD as well as how to prevent work disability [12].

It has been recognized that PTSD may result from occupational exposure to traumatic incidents that workers have been exposed to in the course of their professional duties, e.g., injury, death, assault, disasters, and acts of terror. Certain professions such as police officers, emergency and rescue personnel, firefighters, bank officers, and train drivers are reported to carry a particularly high risk of exposure to traumatic events [13]. Berger et al. [14] conducted a meta-analysis which examined the worldwide prevalence for current PTSD among rescue workers and found rates of 14.6%for emergency personnel, 7.3%for firefighters, 4.7%for police officers, and 13.5%for other rescue teams.

There are a growing number of studies providing estimates of PTSD prevalence [13, 14]. However, there remains a gap in the literature exploring the association between occupations and PTSD. Examining the growing number of studies evaluating the effectiveness of PTSD treatments [15 –18] may help to better understand the association between occupation and PTSD. The association between occupation and PTSD is important to insurance and compensation systems as they may be required to cover the costs associated with work absence due to PTSD [19 –22]. Therefore, we set out to review the literature to answer the question: “Which occupations have exposures that may lead to a PTSD diagnosis?”

2 Methods

This rapid review used a systematic approach with the following steps: review question development, literature search, study selection (inclusion/exclusion), study characterization, data extraction, and data synthesis. A rapid review employs methods to accelerate or streamline traditional systematic review processes [18], providing evidence to decision makers in a short time frame [23]. The rapid review approach was adapted from established methods [24 –27] and the IWH systematic review methods [28]. Ethics approval was not required for a review of the literature.

2.1 Review question

The review question was developed in an iterative process by the review team and stakeholders (members of a workers’ compensation board) to ensure the question was relevant.

2.2 Literature search

Search strategies were developed based on the review question to identify relevant published literature in six electronic bibliographic databases. Search terms were developed iteratively by our research team, which included a librarian, for three broad areas: population (occupations/workers), intervention/exposure (PTSD and accidents/incidents), and outcomes (insurance coverage/compensation and quality of life/return to work). Both database-specific controlled vocabulary terms and keywords were included for each database. Search development was checked by ensuring that relevant articles were included in the results. A full electronic search strategy for MEDLINE (OVID), can be found in the Appendix.

We searched the following databases, with no language restrictions, limiting results to 2008 to 2018: MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), PsycINFO (OVID), Social Sciences Ab-stracts (Proquest), and Cochrane Library (Wiley).

2.3 Study selection (inclusion/exclusion) criteria

We considered articles that described occupational exposures and provided information regarding the association with PTSD regardless of study design. As this was a rapid review, we only included articles published from 2008–2018 [25]. Selection of relevant studies (those that described occupational exposures and PTSD) took place in two stages. In the first stage, titles and abstracts of identified references were reviewed based on our inclusion/exclusion criteria in order to exclude studies not relevant to our research question. For those titles and abstracts that met the inclusion criteria or with insufficient information in title and abstract to determine relevance, full-text articles were retrieved for review in the second stage where the same inclusion/exclusion criteria were applied. At each stage, rotating pairs of reviewers screened references for relevance. Disagreements were examined until consensus was achieved. If agreement could not be reached, a third reviewer was consulted. Non-English language studies were reviewed by team members or IWH staff with the requisite language proficiency.

2.4 Data extraction and synthesis

We extracted relevant data from each study that would help us address the question of: “Which occupations have exposures that may lead to a PTSD diagnosis?” Data describing occupations that included PTSD sufferers as well as information about PTSD diagnosis and the types of injuries that were involved was extracted along with data related to jurisdiction. The full review team met to extract the data from the relevant studies for synthesis. Methodological quality of the studies was not evaluated as this is a rapid review and the review question is descriptive and explores the associations between occupation and PTSD.

Our synthesis approach was qualitative, describing the occupation information available in studies that examined some aspect of PTSD. We used the occupation categories found in a narrative review by Skogstad et al. [29] as a framework for synthesizing the occupation information from the studies we found. Our synthesis provides details available in the peer-reviewed literature regarding occupations and occupational exposures that appear to be related to PTSD.

3 Results

The search identified 4677 articles. After removing duplicates, we screened 3428 titles and abstracts and 102 full-text studies for relevance. Further, we retrieved 38 papers from the reference lists of the included studies. This resulted in the identification of 16 studies (23 papers) for inclusion in this review (see Fig. 1). One study was in German. We present the results according to the occupational categories described by Skogstad and colleagues [29]. Table 1 shows the characteristics of the included studies according to occupational category.

Fig. 1

Flowchart of study identification, selection and synthesis.

Table 1

Characteristics of included studies, organized by occupation

Author	Jurisdiction	Occupation	Exposures	Prevalence	How diagnosed: Criteria
Berger (2012) Systematic Review	Various	Rescue workers: (ambulance workers, canine handlers, firefighters, and police officers involved in rescue operations)	A traumatic event, defined by the DSM-IV-TR as experiencing, witnessing, or being confronted with at least one event involving actual or threatened death or serious injury, or a threat to the physical integrity of self or others	The worldwide pooled current prevalence was 10%.	Self-report: DSM criteriaInterviews: DSM criteria
Farnsworth (2011)	USA	Firefighters	Traumatic events (not defined)	NA	Self-report: Posttraumatic-Disorder Checklist-Civilian Version (PCL-C)
Halpern (2009)	Toronto, Ontario, Canada	Ambulance workers	Critical incidents, defined as “any situation faced by emergency personnel that causes them to experience unusually strong emotional reactions which have the potential to interferewith their ability to function either at the scene or later”	NA	NA
Maguen (2009)	New York, New York, and San Francisco Bay Area, California, USA	Police officers	List of 14 items that were personally life threatening to police officers	NA	Self-report: Mississippi Combat Scale-Civilian Version (MCS-CV)
Martin (2009)	Montreal, Quebec, Canada	Police officers	Various, including: being a witness of suicide, homicide, or conjugal violence; being involved in a school shooting; being threatened with a firearm; being injured; injuring a suspect; or shooting someone	Following their most traumatic duty-related event, almost 8% (n = 10) of the officers developed full PTSD, 7% (n = 9) developed partial PTSD	Qualified Interviewers: Entire PTSD module of SCID-1, DSM-IV
Misra (2009)	London, UK	Ambulance workers	Suicide bombings and aftermath	Overall, 4% of the sample reported probable PTSD. Those involved with the response to the bombings were more likely to report probable PTSD (6% )	Self-report: Trauma Screening Questionnaire
Alden (2008)	Canada	Hospital emergency department (ED) medical staff	Direct threat: primary work-related stressing event was threatened or actual harm to themselves	NA	Self-report: Post-traumatic Stress Diagnostic Scale (PDS)
			Witnessed threat: primary work-related distressing event was actual or threatened death to patients
Mealer (2009)	Colorado, USA	Nurses	A traumatic incident (not further defined) that occurred while working in the hospital	22% percent (73/332) had symptoms of PTSD, 18% (61/332) met diagnostic criteria for PTSD	Self-report: Post-traumatic Diagnosis Scale (PDS)
Bender (2016); Links (2016); Bance (2014)	Toronto, Ontario, Canada	Transit workers	Serious or fatal collisions, physical violence, person under train (PUT) incidents (most often suicides or attempted suicides) and verbal harassment	NA (However, TAU and BPI significantly differed on the occurrenceof Axis-I diagnoses; compared to the TAU agreater proportion of BPI participants met criteria for PTSD (38.7% vs. 55.3%, respectively)	Self-report: four weeks post-incident with the Modified PTSD Symptom Scale (MPSS).
					Self-report: Axis I and Axis II DSM disorders were also assessed with the Structured Clinical Interview for DSM-IV disorders (SCID I and SCID II).
					Self-report: At 3- and 6-months post-incident with the Modified PTSD Symptom Scale (MPSS)
Clarner (2015) Systematic Review	Various	Transit workers	Traumatic events such as suicides or accidents involving damage, injury, or death	PTSD prevalence varied broadly between 0.7 and 17 %	Various: validated instruments (self or external) or based on standard diagnostics (ICD-9; ICD-10; DSM-III, DSM-IV)
Clarner (2017)	Nuremberg, Bavaria, and Frankfurt/ Main, Hesse, Germany	Transit workers	Potentially traumatic events (PTEs) including accidents, collisions, suicides or violence	NA	Admin records and Psychiatrist: Occupational accidents and qualifying for ICD-10:F43.0.Severity of the PTE.
Clarner (2015)	Nuremberg, Bavaria, Germany	Transit workers	Accidents, collisions, suicides, threats, or attacks	The incidence of psychotrauma was 44.1%, with 8.5% showing post-traumatic stress disorder (PTSD) as consequence of the accident	Psychiatrist: Classification according to ICD-10.For longer-term disorders such as PTSD (ICD-10 F 43.1)
Fichera (2015)	Italy	Bank employees	Robbery	NA (However, there were 383 participants. At T2, 13% of subjects had an Impact of Event Scale (IES) score > 34, a cut-off suggestive of PTSD.)	Self-report:Impact of Event Scale (IES)
Anderson (2001)	Washington State, USA	Construction and extraction, electricians, production, installation, maintenance and repair, and transportation and material moving	Work-related burn injuries	NA (However, 19.8% of the sample had an associated psychiatric diagnosis)	Washington State Workers’ Compensation data: ICD-9 codes (309.81 Posttraumatic stress disorder)
Hensel (2010); Hensel (2011)	Toronto, Ontario, Canada	Occupation types: Professional, clerical/retail, protective services, labour, and other	Event types: Accidents/strain or robbery/assault	NA (However, 531 referred workers were included in the study. Posttraumatic stress disorder was the primary diagnosis in 44%. 58% had one or more secondary diagnoses.)	Trained psychologist: Structured Clinical Interview for the DSM IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.) Axis I Disorders (SCID-I version 2)

For rescue workers (Police officers, firefighters, ambulance personnel, canine handlers), Martin et al. [30] conducted structured interviews with 159 Canadian police officers. Among those that were exposed to work-related traumatic events, almost 8%had full PTSD and 7%had partial PTSD according to DSM-IV criteria.

Berger et al. [14] completed a systematic review and meta-analysis to compare the prevalence rates of PTSD among 19,835 rescue workers exposed to a traumatic event, defined by the DSM-IV-TR. Rescue workers were defined as including ambulance workers, canine handlers, firefighters, and police officers involved in rescue operations. The review findings revealed that rescue workers have a 10%pooled worldwide prevalence of PTSD. Furthermore, they reported that the average prevalence of PTSD in ambulance workers is higher than that for firefighters and police officers involved in rescue work. Geographical location also showed variation with higher prevalence estimates for ambulance personnel in Asia compared to other jurisdictions.

Maguen et al. [31] conducted a study examining the relationship between routine work environment stress and PTSD in a sample of 180 police officers in the United States of America. PTSD was diagnosed using the Mississippi Combat Scale-Civilian Version (MSC-CV) among officers who experienced threats to their lives. They found that routine stress in the work environment was more strongly associated with PTSD than other factors such as gender, ethnicity, negative life events, and prior traumatic exposure.

A study by Misra et al. [32] assessed the psychological impact of the 2005 London bombings on ambulance personnel. They found that four percent of the sample (n = 321) had probable PTSD as diagnosed by the Trauma Screening Questionnaire, a well-validated screening tool used in several studies of post incident trauma. However, a higher proportion (6%) reported probable PTSD among those directly involved in the London bombings incident.

Two additional studies considered PTSD among rescue workers. Farnsworth and Sewell [33] considered American firefighters diagnosed with PTSD using the Posttraumatic-Disorder Checklist-Civilian Version (PCL-C), a 17-item self-report measure of PTSD symptoms. The focus of the paper was to examine negative social interactions as a predictor of PTSD symptoms. They found there was no association between social interaction and PTSD symptoms. However, they point out that a lack of association does not mean that social interaction is not important for PTSD treatment. Halpern [34] examined the critical incidents described by Canadian ambulance workers with PTSD (diagnostic criteria not reported) in a qualitative study. They found that the 60 participants noted that the critical incidents usually involved patient death, which caused considerable distress. Barriers to getting support for PTSD were greater when there was difficulty acknowledging the distress accompanied with fear of stigma.

With respect to health care professionals, Mealer et al. [35], conducted a survey of 332 nurses exposed to a traumatic incident in university hospitals in the United States of America and found that 18%met the diagnostic criteria for PTSD using the Post-traumatic Diagnostic Scale (PDS), a validated instrument.

Alden et al. [36] compared PTSD symptoms in 100 staff members of a hospital emergency department in Canada who had experienced either a direct threat to themselves or witnessed a threat to a patient. While there were differences in the symptom profiles, they found that both groups experienced PTSD symptoms using the PDS.

A number of studies examined transit drivers (Train, bus, subway) and their exposure to traumatic events and PTSD.

Clarner et al. [37] evaluated 59 employees of a Bavarian public transportation company for trauma-related disorders following an accident or traumatic incident at work. The study found that 44.1%showed some signs of psychological trauma, with 8.5%showing signs of PTSD, using the ICD -10 classification.

Bender et al. [38 –40] reported that transit workers (workers in transportation, especially those who operate subways, trains, buses) are at risk for witnessing traumatic incidents and therefore PTSD. Traumatic events in this occupational setting may include serious or fatal collisions, physical violence, person under train (PUT) incidents (most often suicides or attempted suicides) and verbal harassment. The study, conducted in Canada, examines the effectiveness of a treatment program where the 126 participants diagnosed with PTSD according to the DSM-IV were recruited from the transportation/transit sector. The study concluded that it had demonstrated the value of workplace interventions on improving awareness of psychological symptoms after exposure to a traumatic incident and the value of screening for PTSD symptoms.

Clarner et al. [41] also noted that transit workers are at a greater risk of witnessing traumatic events and may suffer from PTSD. However, they chose to use a different term, potentially traumatic event (PTE), to explore the risks among 259 transit drivers in Germany. The PTE definition used was according to ICD-10:F43.0 where PTEs are characterized by experiencing extraordinary mental or physical stress.

A single study [42] examined the incidence of PTSD among 383 bank workers in Italy who were victims of a robbery. The Impact of Event Scale (IES), a 15-item self-reported measure of post-traumatic symptoms, was administered to participants. The IES has been shown to have strong agreement with a PTSD clinical diagnosis and is sensitive to clinical changes. The study found that 13%of the participants reached the IES cut-off point for PTSD. The bank employees were involved in an employer-sponsored post-robbery support group.

There were other occupation categories that were studied in this review. Anderson et al. [43] examined 329 American hospitalized workers with burn injuries and their psychiatric sequelae including PTSD (according to the ICD-9). They found that burn victims with a psychiatric diagnosis were most often from the following occupational groups (NAICS): Construction and extraction, electricians, production, installation, maintenance and repair, and transportation and material moving.

In addition, we found a PTSD treatment study that included workers diagnosed using the DSM-IV from various occupation types. Hensel et al. [44, 45] recruited 531 workers for a PTSD treatment study from the following occupation types: Professional (13%), clerical/retail (12%), protective services (11%), labour (43%), and other (21%). It is important to note that the proportions are not indicative of the prevalence rates within these occupations but rather characteristics of workers presenting to a Psychological Trauma Program (PTP), a specialized provincial workers’ compensation board assessment program for workers with psychological sequelae of workplace trauma in Toronto, ON.

In summary, across the studies, a variety of occupations were examined including: hospital emergency department (ED) medical staff, nurses, construction and extraction, electricians, production, installation, maintenance and repair, and transportation and material moving, transit workers, rescue workers (ambulance workers, canine handlers, firefighters, and police officers involved in rescue operations), and bank employees. Skogstad et al. [29] included the occupations of journalists and sailors, however we found no studies published after 2008 that described the association between these occupations and PTSD.

4 Synthesis

Our review set out to answer the question “Which occupations have occupational exposures leading to a PTSD diagnosis?”

To answer this question, we conducted a rapid review of the peer-reviewed literature that reported on a association between occupation, occupational exposures and PTSD. We searched for and included literature from 2008 to April 2018 from six electronic databases and included all languages. The review was completed in four months.

We found 16 studies described in 23 articles that provided information related to answering the review question. The studies examined a variety of occupations. As the focus of the review was on occupations and PTSD, we presented the review findings in occupation categories according to a literature review by Skogstad et al. [29] to allow for comparability with earlier literature on occupations and PTSD.

4.1 Diagnosis of PTSD

PTSD was diagnosed utilizing many tools (ICD-9; ICD-10; DSM-III, DSM-IV, Posttraumatic Diagnosis Scale (PDS), Modified PTSD Symptom Scale (MPSS), Posttraumatic-Disorder Checklist-Civilian Version (PCL-C), Impact (IES), and the Mississippi Combat Scale-Civilian Version (MCS-CV). The heterogeneity among the PTSD measures used is a concern as it limits the comparability of the study outcomes (prevalence or intervention). Many studies referred to the classification of mental disorders as given in Chapter V: Mental and behavioural disorders of the ICD -10 (the 10th revision of the International Statistical Classification of Diseases and Related Health Problems) by the World Health Organization (WHO) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994) (or DSM-5, 2013) by the American Psychiatric Association. However, there are differences in prevalence depending on the diagnostic criteria used. Kilpatrick [46] conducted a national survey study of stressful events to compare DSM-5 and DSM-IV diagnostic criteria. They found that while 11.5%met the DSM-5 criteria for a work exposure, all DSM-5 prevalence estimates were slightly lower than their DSM-IV counterparts. In addition, DSM-5 PTSD prevalence was higher among women than among men. Kilpatrick points out that the exclusion of non-accidental, nonviolent deaths and the requirement to have at least one active avoidance symptom resulted in the differences in prevalence between DSM-IV and DSM-5 criteria. These are just some examples as to why it is important to consider the heterogeneity of diagnostic criteria in the different studies.

4.2 Prevalence of PTSD in specific occupations

There were studies that estimated the prevalence of PTSD according to occupation. These studies indicated that the prevalence of PTSD in a sample of Canadian police officers was 8%[30] while a systematic review and meta-analysis determined the prevalence of PTSD among rescue workers worldwide was 10%[14]. One study [35] reported that the prevalence of PTSD among nurses was 18%. A study by Clarner et al. [37] found a prevalence rate of 8.5%among Bavarian public transportation workers, however, a systematic review by Clarner et al. [47], also published in 2015, showed that the prevalence estimates for transit workers varied between 0.7 and 17%. Looking beyond prevalence studies we note that studies examining PTSD interventions or supports often described sampling from specific occupations such as transit workers [37, 39], firefighters [33], bank employees [42], ambulance workers [34], and police officers [31]. One intervention study by Hensel [44] described subjects coming from a variety of occupations (professional, clerical/retail, protective services, and labour).

4.3 Exposures related to PTSD

The studies we reviewed covered a variety of occupational exposures which included: traumatic events, work-related burn injuries, serious or fatal collisions, physical violence, person under train (PUT) incidents (most often suicides or attempted suicides) and verbal harassment. Examples of traumatic events included: experiencing or witnessing at least one event involving actual or threatened death or serious injury, or a threat to the physical integrity of self or others, accidents, collisions, violence, robbery, assault, shooting, bombings and their aftermath. The exposures were consistently described as traumatic and often associated with the diagnostic criteria used in the studies. For example, a traumatic event is defined by the DSM-IV-TR as experiencing, witnessing, or being confronted with at least one event that involves actual or threatened death or serious injury, or a threat to the physical integrity of self or others. As well the ICD-10 definition indicates that PTSD arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.

4.4 Strengths and limitations

The strengths of this review are that it used a rigorous methodology and was conducted by an experienced team of researchers. While the team used a rapid review method, the literature search was conducted in six databases and did not limit by language. Potential limitations of the review are that it only covered 10 years and did not include a quality appraisal of the included studies. However given the paucity of studies, it is important to document the associations between occupation and PTSD to guide future studies. A further limitation inherent in conducting a rapid review is that, by definition, the method is intended to provide evidence to decision makers in a short time frame. This brings about issues of feasibility for reviewing as much relevant literature as possible [23].

5 Conclusion

Through a rapid review of the literature, we set out to search for evidence that describes which occupations have exposures that may lead to a PTSD diagnosis. Unfortunately, there were few studies that directly answered our review question that were published between 2008 and 2018. However, a few recent studies found by our search provided some details relevant to the question of a association between occupations and PTSD. We used the occupation categories from a narrative review by Skogstad et al. [29] that examined PTSD in occupational settings. Within these categories we reported the prevalence for the occupation (if applicable), the diagnostic criteria and the types of occupational exposures described within the included studies. While the Skogstad review did not include intervention studies, we included those that provided information about the occupations of the study participants.

In answering our review question, the key findings of the rapid review of articles about PTSD prevalence and treatment supports previous findings that first responders face occupational exposures that are consistently associated with PTSD. This literature also suggests associations between PTSD and healthcare workers (particularly emergency department and nursing), transportation workers, and bank employees. While less often mentioned there are possible associations between construction, production, and maintenance and repair workers.

The occupational exposures most often associated with PTSD diagnosis were related to traumatic events such as experiencing or witnessing death or serious injury, accidents, serious or fatal collisions, violence, robbery, or assault. Additional occupational exposures associated with PTSD were work-related burn injuries, suicides or attempted suicides, and verbal harassment. It is therefore possible that any occupation where these exposures are present may result in a PTSD diagnosis.

This rapid review provides a current picture of occupation and PTSD via prevalence estimates from a variety of studies and supporting information from additional studies about PTSD treatment. We suggest using caution when interpreting the review results as there is great heterogeneity among the studies with respect to diagnostic criteria and exposure measures. In addition, the population of workers within the studies is quite heterogeneous e.g. one worksite vs. one jurisdiction or a whole geographical region with a mix of occupations. Some studies focus on workers involved in either a specific event e.g. London bombing vs. the cumulative effect of trauma through multiple “events”. Our team used a rigorous review approach to augment and update the findings of a review by Skogstad et al. [29] whose search was conducted in 2010.

It is important to consider that the prevalence rates from the individual studies could be under-estimates. In their systematic review and meta-analysis, Berger et al. [14] state, in their review conducted in 2008, that the prevalence estimates are very likely underestimates as traumatized workers tend to retire earlier and as a result are unavailable to participate in research.

Recent research shows that PTSD is a strong predictor of compensation claim duration and disability [48, 49]. This rapid review of the literature found that a diverse set of occupations may be associated with PTSD diagnosis. Workers exposed to traumatic events regardless of occupation may develop PTSD. The burden of PTSD is substantial to workers and workplaces. There is a need for more rigorous, high quality research on occupational exposure and PTSD for compensation and insurance systems to have stronger evidence of the association so that they may better support those affected by workplace-based PTSD, through presumptive coverage, for example. A more complete understanding of the association between occupational exposure and PTSD diagnosis is an important step to prevention and reducing the burden.

Conflict of interest

None to report.

Footnotes

Acknowledgments

This research project was funded by a grant from WorkplaceNL. The Institute for Work & Health operates with the support of the Province of Ontario. The views expressed in this manuscript are those of the authors and do not necessarily reflect those of the funder or the Province of Ontario. We would like to thank Ms. Joanna Liu, Library Technician, for her contributions to this project.

The appendix is available in the electronic version of this article: .

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