Reference: JAMA Netw Open 2026 Feb 2;9(2):e2557241
Practice Point: Integrating cognitive resilience training into paramedic education appears to be a valuable and effective approach for preventing the development of PTSD.
EBM Pearl: An odds ratio is typically a good approximation of the easier-to-understand concept of relative risk when the outcome is rare, but it tends to exaggerate an association when prevalence is high (> 10%).
It’s a sad irony that those who seek to save lives are among those most at risk of taking their own due to mental health issues. Paramedics work in pressure cooker situations and are repeatedly exposed to images they can never unsee and sounds they can never unhear. Add to that irregular work shift patterns, and a propensity toward posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) seems almost inevitable. Despite the fact that research has uncovered two cognitive processes involved in the development of PTSD and MDD—rumination and maladaptive resilience appraisals—to date, no targeted treatment modalities have been shown to be effective in the prevention of PTSD. Until now.
A recent randomized trial evaluated a specific form of cognitive behavioral therapy targeting the modifiable risk factors that put paramedics at risk for PTSD and MDD. 570 paramedic students in England were randomized 1:1:1 to receive 1 of 3 treatments: internet-delivered cognitive training in resilience (iCT-R), psychoeducation, or standard care. iCT-R consisted of 6 weekly internet-delivered modules using active, experiential approaches adapted from cognitive behavioral therapies for PTSD and social anxiety disorder and rumination-focused therapy for depression. Psychoeducation involved 6 weekly (noninteractive) modules that addressed sleep, stress, depression, anger, mindfulness, and PTSD. Both the iCT-R and psychoeducation arms also received templated email-based coaching and follow-up exercises for 6 months. Standard care consisted of the usual paramedic training and support services without additional remote services.
At 1 year, PTSD or MDD was diagnosed in 1.5% with iCT-R, 5.6% with standard care, and 7.1% with psychoeducation. For iCT-R, this translates to an odds ratio of 0.2 compared to psychoeducation, with an NNT of 18-24. Overall event rates (new PTSD or MDD diagnoses at 1 year) were low, which is important because an odds ratio is a good approximation of relative risk when the outcome is rare, as in this case. To the contrary, when outcomes are common (> 10%), odds ratios exaggerate the strength of association compared to relative risk. The low event rates also make it harder to draw conclusions about secondary outcomes, but in this study iCT-R was also associated with less severe PTSD and depression symptom scores compared with standard care.
Anecdotally, getting first responders such as firefighters and paramedics to go to therapy after 1 year or 20 years of traumatic exposure is not easy, and even if they do, long-term therapy can typically offer moderate symptom improvement at best. I’ve seen way too many first responders with cirrhosis because they self-medicated their trauma away. So, if iCT-R incorporated into training requirements could reduce PTSD and MDD, and by extension suicide and substance misuse, even just a little, it would be a game changer. While we’ll admit that the details of what iCT-R actually entails probably remains best understood by trained psychologists, it is clear that integrating this type of cognitive resilience program into first responder training could offer meaningful protection against a variety of mental health conditions and may very well save the lives of the life savers.
For more information, see the topic Posttraumatic Stress Disorder (PTSD) in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Katharine DeGeorge, MD, MS, Executive Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia. Edited by Alan Ehrlich, MD, FAAFP, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School; McKenzie Ferguson, PharmD, BCPS, Senior Clinical Writer at DynaMed; Rich Lamkin, MPH, MPAS, PA-C, Senior Clinical Writer at DynaMed; Claire Symanski, PhD, Medical Editor and Team Lead for ENT at DynaMed; Michael Butler, PhD, Medical Writer at DynaMed; Matthew Lavoie, BA, Senior Medical Copyeditor at DynaMed; Hannah Ekeh, MA, Senior Associate Editor II at DynaMed; and Jennifer Wallace, BA, Senior Associate Editor at DynaMed.