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• Mental distress and suicidality are not more prevalent among California's first responders than among workers in other occupations who are exposed to trauma on the job.
• Claims filed by firefighters and peace officers are more likely to involve PTSD than are claims by the average worker in California but are also denied more often.
• First responders' PTSD claims are denied more often than claims for other conditions (e.g., cancer or heart trouble) with a presumption of being work-related.
• Although it is often feasible to prove that a mental health condition is job-related, there are barriers that contribute to potentially avoidable claim denials.
• Firefighters and peace officers also face barriers to care-seeking — primarily, mental health stigma, fear of professional consequences, and lack of access to culturally competent mental health providers who understand the realities and exceptional demands of their work.
• Nearly all workers interviewed filed workers' compensation claims for mental health conditions, but almost none received PTSD care paid for by workers' compensation; rather, nearly all paid for care out-of-pocket, sometimes causing severe financial strain.
• Without SB 542, first responders' workers' compensation claims involving PTSD would cost state and local governments an average of $20 million per year in benefit costs. Under SB 542, costs for claims involving PTSD may increase substantially. Costs under SB 542 are highly uncertain, however, and could range from $48 million to $347 million per year.
• A retroactive presumption covering PTSD with 2017–2019 injury dates might cost $79 million, although these costs are also highly uncertain.

In 2019, California enacted Senate Bill (SB) 542, which created a rebuttable presumption that posttraumatic stress disorder (PTSD) in firefighters and peace officers is a work-related injury and thus compensable under workers' compensation.

California has long used presumptions to facilitate workers' compensation claims for many other occupational health conditions in first responders, including cancer, heart trouble, and hernia. SB 542 is intended to encourage care-seeking among first responders and reduce the stigma associated with filing a workers' compensation claim for a mental health condition. The presumption is in effect for injuries occurring between January 1, 2020, and December 31, 2024.

The authors of this report evaluate the prevalence of mental health conditions and illnesses among firefighters and peace officers and discuss the implications that this evidence has for policy regarding presumptions established by SB 542. Using a mixed-methods approach, the authors also investigate the frequency of workers' compensation claims involving PTSD, how often these claims are denied, and how first responders experiencing PTSD access mental health care. First responders' mental health and experiences in the workers' compensation system are compared with those of workers in other trauma-exposed occupations. Claims involving PTSD are compared with claims involving other health conditions — such as cancer, heart trouble, and hernias — that are also presumed to be work-related in first responders under California law. The report also contains estimates of the costs to state and local government that might result from presumptive coverage of PTSD in the workers' compensation system, and the authors also discuss stakeholder perspectives on SB 542.

• Chapter One

  Introduction

• Chapter Two

  Background and Overview of Study

• Chapter Three

  Posttraumatic Stress, PTSD, and Suicide Among First Responders

• Chapter Four

  PTSD in California's Workers' Compensation System

• Chapter Five

  Proving the Job-Relatedness of Mental Health Claims

• Chapter Six

  Access to Mental Health Care for First Responders

• Chapter Seven

  Costs of PTSD Claims and Potential Cost Impacts of SB 542

• Chapter Eight

  Stakeholder Perspectives on SB 542 and Areas to Improve

• Chapter Nine

  Policy Recommendations and Future Research Priorities

• Appendix A

  Question-by-Question Summary of Findings

• Appendix B

  Additional Information on Qualitative Methods

• Appendix C

  Additional Information and Supplementary Results on Quantitative Analyses

• Appendix D

  Comparison Occupations and O*Net Work Context Measures