Rita, director of nursing at a Southern California university (who asked not to use her real name), experienced her first episode of major depression in 1991, while in the process of moving to Southern California from Pennsylvania. Shed had a rough year-and-a-half both her parents died and she had to sell their house and buy a condo in California. She felt exhausted, sad, and overwhelmed, incapable of making even simple decisions. At one point, she recalls staring into a drawer, unable to choose a piece of clothing. When a friend gave her the number of a mental health counselor, she burst into tears.
After counseling and medication, Rita came out of the depression. She has had two more episodes since. The last occurred about three years ago after a particularly stressful time at work.
While Rita does not believe nursing causes depression, she does think it attracts people who demand a lot of themselves, which can set them up for stressful situations that may lead to depression. My particular makeup is one of a caretaker, she says. When I cant fix something, thats a black mark on my record.
Rita is clearly not alone in her ongoing struggle with this illness. Some 9.6% of full-time healthcare practitioners between the ages of 18 and 64 suffered a major depressive episode in the year before an October 2007 report published by the U.S. Substance Abuse and Mental Health Services Administration compared with 7% among all full-time workers.
For workers between 18 and 25 years old the age group most likely to have experienced a major depressive episode in the past year the highest rates of depression out of 21 occupational categories were among healthcare practitioners and those in technical occupations. Depression symptoms include persistent sadness; significant changes in sleep, appetite, and energy levels; difficulty concentrating; lack of interest in once enjoyable activities; feelings of worthlessness and hopelessness; recurrent thoughts of death; and physical symptoms that do not respond to treatment, such as headaches, chronic pain, or digestive disorders.
Major depression is a leading cause of disability in this country. Without treatment, according to the National Alliance on Mental Illness, the frequency and severity of the symptoms of major depression can increase over time and may lead to suicide. There is evidence of a genetic predisposition to the disease, so those who have a family history of depression are at increased risk. When job stress is added to the mix, it may increase that risk even more, some say.
T. Larry Myette, MD, MPH, the director of strategic workplace health for Canadas Healthcare Benefit Trust and a clinical assistant professor at the University of British Columbia, is an occupational health physician who has studied depression in the workplace. In the case of nurses, theres a high demand placed on them and limited ability to control it, he explains. These factors can be exacerbated in times of staffing shortages. While surveys have shown nurses to score highly on job satisfaction, they also score highly on work-related stress.
This is backed up by data from the American Nurses Association. The ANA annual staffing survey, released in May 2008, found nearly 52% of the more than 10,000 nurses who responded were considering leaving their positions (46% said the reason had to do with inadequate staffing), and 23.8% said they were considering leaving nursing, according to a spokeswoman.
A Harvey Research Inc. study commissioned by Gannett Healthcare Group found 36.8% of 2,600 readers polled would consider leaving their current nursing positions. Their top three priorities in looking at a new job were appealing work hours, higher pay, and respect for nurses. Another 7.5% were actively planning retirement.
Long-term exposure or chronic exposure to stressors, particularly high-level stressors at work, appear to be linked to depression in workers, says Naomi Swanson, PhD, a supervisory research psychologist with the National Institute for Occupational Safety and Health. Stressors common in healthcare settings, she notes, include inadequate staffing levels, long work hours, shift work, and exposure to infectious and hazardous substances. Furthermore, she says, studies of nurses have found work overload, time pressure, lack of social support, needlestick injuries, role ambiguity, and dealing with difficult or seriously ill patients all contribute to stress levels.
Patricia Carter, RN, PhD, CNS, an associate professor at the University of Texas at Austin School of Nursing, has conducted a number of studies that show lack of sleep makes many caregivers, including nurses, more prone to irritability and anger toward those they are caring for, which often leads to guilt, anxiety, depression, and more sleep problems, she says. The difficulty in sleeping sets up a risk for depression even in a person who has never had a history of depression before.
Finding Meaning in Work
Jo Anne, a nurse in central Washington (who asked that her name not be used), says she was diagnosed with bipolar disorder before she went to nursing school. She now works part-time in an ambulatory care clinic, a job she chose in part to avoid rotating shifts or the intense hours of hospital work. She is aware the stress of her job may trigger depression, but at the same time, she says, she chose nursing because she wanted work that felt meaningful to her, and she believes caring for patients helps maintain her own stability.
My being able to calm them a little through the procedures theyre going through helps me, she says. As long as I know that Im helping them, then it does take my mind off of me.
Ann Bispo, RN, MSN, CNS, president of the California chapter of the American Psychiatric Nurses Association and a clinical nurse specialist at the Community Hospital of the Monterey Peninsula in Monterey, Calif., says nurses need an opportunity to debrief after traumatic patient encounters. If people dont have healthy ways to cope, that takes its toll, she says.
The good news about depression is that it is highly responsive to treatment, say psychiatric nurses and other experts. While individual responses vary, the best results often come from a combination of therapy and medication, they say. And the variety of medications available today is greater than ever before.
But nurses also often put their own care at the bottom of a long list, and may ignore symptoms of something going wrong. Rita and others say even though they knew they had a history of depression or had treated people with depression and knew the signs well, episodes of the illness have snuck up on them.
Depression may be particularly difficult for nurses, physicians, psychologists, and other caregivers to admit, says Julie Nelligan, PhD, a licensed psychologist in private practice in Portland, Ore. Were supposed to be the healers, so its really big to say, Ive got a problem.
But as nurses with the illness explain, depression does not have to be a life sentence. Both Rita and Jo Anne say their depression has helped them better understand and help others, especially those in pain. They monitor themselves carefully and ask trusted others to watch as well for mood and behavior changes. They make a point of taking care of themselves eating right, exercising, taking needed breaks. They try not to bring their work home with them.
Barbara Kirchheimer is a freelance writer. Cathryn Domrose is a staff writer for Gannett Healthcare Group.