Institute of Health Dr. Smith and Strfbia Rabold, NP discuss results showing that among the 62 participants who completed the IOH first responder program, 93.6% no longer met diagnostic criteria for PTSD at discharge and 93.6% returned to work. Conducted by the City of San Diego and Institutes of Health, this research was presented to the American College of Occupational and Environmental Medicine (ACOEM) in April 2025.
By Corey Dahl
First responders are more likely to die from suicide than in the line of duty — and the City of San Diego’s Workers’ Compensation Program wants to do something about that.
Joseph Sousa, the program’s manager, found that just under 70% of the city’s total workers’ comp losses came from its police and fire rescue departments. While many of those claims are due to physical injuries, many others are the result of post-traumatic stress disorder (PTSD) due to frequent exposure to intense trauma.
California passed legislation in 2020 making PTSD a presumptive injury for peace officers and firefighters. This legislation, combined with industry statistics, claim reviews and personal accounts, spurred Sousa to figure out how to better address physical injuries and illnesses as well as emotional scars and mental distress for first responders.
Barriers to Treatment
Treating PTSD can be difficult. There aren’t many workers’ compensation providers with experience treating complex mental health conditions, Sousa says. The providers who do offer treatment usually rely on the same framework for all injuries and don’t recognize PTSD as a presumption injury, causing treatment delays.
First responders also face a stigma associated with mental health assistance. Many fear that admitting emotional distress will be seen as a weakness by their leaders and peers — and could potentially jeopardize their job.
Additionally, PTSD claims tend to come with high medical bills, long absences and extra costs for overtime pay. And even after all of that, many first responders will show little or no improvement following treatment. They might be off the job for up to two years, or if they do return, they could relapse immediately.
Sousa set out to find a better way. He worked with wellness group leaders in both the police and fire departments to gather input on what would make the program better. Sousa knew it was important to get these leaders onboard, as they’re the first point of contact for first responders when they request assistance.
“Unfortunately, there tends to be an adverse relationship between risk departments and police and fire departments,” Sousa says. “We have worked really hard in building those relationships. At the end of the day, we have similar goals: We want to take care of our employees, and we want to get our employees back to work, with the claim concluded.”
Expanding the Safety Net
Employee education was essential. Many didn’t know about the options available to them; others had been stuck in slow claims processes in the past. Sometimes, the department wouldn’t know there was a problem until an employee’s attorney reached out, Sousa says.
“We learned to keep our focus on the employee,” he says. “The employee tends to get lost in this workers’ comp process. So we work to educate them along the way; what the process looks like, what benefits they’re entitled to. We’ve been able to remediate a lot of unnecessary delays in the process by focusing on educating employees.”
Sousa also recognized that previous approaches to PTSD treatment had been fragmented, driving up costs and rendering the treatment ineffective. He reached out to a group of specialty clinics that specialize in treating PTSD, and the clinical team expressed a willingness to work together to address first responders’ unique concerns.
A partnership between the city and the Institutes of Health followed, resulting in the creation of a clinical model for first responder treatment that has become the gold standard for PTSD treatment.
The program is rooted in evidence-based, biopsychosocial principles. Treatment is delivered in a therapeutic community setting among peers, so first responders work together to heal. They have access to a range of clinical specialists, all under one roof, and clinical notes are shared in real time, so personal care plans can be updated seamlessly.
First responders receive out-patient care once they leave in-patient care, and the police and fire departments now offer peer support and other resources for employees.
“It isn’t just on the workers’ comp provider,” says David Picone, a retired San Diego Fire-Rescue battalion chief who worked closely with Sousa to develop the program. “In order for this to work, the agency has to step up to the plate to do both preventive and post-treatment work.”
The program’s results have exceeded expectations. Participants have been able to return to work in a full-duty role in six to eight months, on average. The program has proven that PTSD recovery is possible, a huge development for the city’s first responders and their families.
“We’ve really reduced the stigma in our first responder population,” Sousa says. “Our numbers for PTSD claims have increased. Our members are coming forward, and they’re not afraid to file a claim because of fear of retribution or losing their job.”
Reaping the Benefits
Even though more first responders are filing claims, Sousa says costs for the program have gone down because employees get treated faster and more effectively. Before implementing the program, claims usually went on for an average of two years, during which the departments paid wage continuation for the affected employees. The new program has employees back to full-time work within one year.
More importantly, fewer first responders are leaving their careers as a result of getting effective treatment for PTSD. That’s beneficial to first responders, who get to stay on the job, as well as for the city. The average police recruit, just out of the academy, represents an investment of $200,000 for the city, while a newly trained firefighter is just over $180,000, Sousa says.
Other key results from the program include:
- Ninety-four percent (94%) of first responders returned to full duty;
- Ninety-four percent (94%) no longer met diagnostic criteria for PTSD;
- Just over five months was the average time to return to work in full-duty capacity; and
- One hundred percent (100%) of first responders who completed the program reached maximum medical improvement.
Sousa is working with other cities to share details and replicate the results of San Diego’s PTSD treatment program.
“It’s not a one-size-fits-all for every city,” he says. “We encourage people to look at their internal processes, bring all the decision makers to the table and put together a program that works for everyone. And, hopefully, at the end of the day, you’ve improved your access to care. The longer we wait to deliver care, the more harm we are creating for the employee — and the higher cost you are forecasting for the claim as well.”