Depression and suicide risk among Nursing professionals : an integrative review

www.ee.usp.br/reeusp Rev Esc Enferm USP · 2015; 49(6):1023-1031 1 Universidade Federal de Alagoas, Programa de Pós-Graduação em Psicologia, Maceió, AL, Brazil. 2 Universidade Federal de Alagoas, Escola de Enfermagem e Farmácia, Curso de Graduação em Enfermagem, Maceió, AL, Brazil. 3 Universidade Federal de Alagoas, Faculdade de Medicina, Maceió, AL, Brazil. 4 Universidade Federal de Alagoas, Escola de Enfermagem e Farmácia, Programa de PósGraduação em Enfermagem, Maceió, AL, Brazil. ABSTRACT Objective: Discussing the factors associated with major depression and suicide risk among nursing professionals. Method: An integrative review in PubMed/MEDLINE, LILACS, SciELO and BDENF databases, between 2003 and 2015. Results: 20 published articles were selected, mostly from between 2012 and 2014, with significant production in Brazil. Nursing professionals are vulnerable to depression when young, married, performing night work and having several jobs, and when they have a high level of education, low family income, work overload, high stress, insufficient autonomy and a sense of professional insecurity and conflict in the family and work relationship. Suicide risk was correlated with the presence of symptoms of depression, high levels of emotional exhaustion, depersonalization and low personal accomplishment; characteristics of Burnout Syndrome. Conclusion: Suicide risk among nursing professionals is associated with symptoms of depression and correlated with Burnout Syndrome, which can affect work performance.


INTRODUCTION
Depression and suicide are complex phenomena that cause intense suffering in the lives of the people affected, their families, friends and community.These two phenomena coexist and influence one another (1) , and both are considered significant public health problems (2) .
The World Health Organization (WHO) (2) estimates that depression accounts for 4.3% of the global burden of disease and is among the largest causes of disability in the world, particularly for women (3) .It also notes that suicide is a universal phenomenon, being the main cause of death among adolescents 15-19 years.In 2012 alone there were 804,000 suicides worldwide, representing a rate of 11.4 per 100,000 (15.0 for men and 8.0 for women) (2) .Both depression and suicide result from the interaction of biological, genetic, psychological, sociological, cultural and environmental factors, while being an important indicator of people's quality of life (4) .
Depression is characterized by a prolongation of depression symptoms and mood swings (5)(6) .The person affected by this disorder has the ability to see the world as an altered reality.Brazil has one of the highest rates of depression; 18.4% of the population has had at least one episode of depression during their lifetime, behind only France (21.0%) and the US (19.2%) (7) .
Brazil also ranked as the fourth country in Latin America to present the highest growth in the number of suicides between 2000 and 2012, with the overall rate of 4.3 per 100,000 inhabitants, but some of its states have significantly higher rates (4) .There was an increase in suicide rates among women of 17.8% in 12 years (2) .
In the world, the number of suicides is higher than deaths from global conflicts every year, with an increase of 60% in their rates over the last 50 years (8) .In acknowledging the relationship between suicide and mental illness, most individuals who ended their lives in this manner had depression (9) .
WHO defines suicide as the act of killing oneself intentionally.For suicidal behavior, a variety of behaviors are considered such as suicidal thoughts, regarded as suicidal ideation, planned suicide, attempted suicide and committing suicide itself.Also, the presence of social, psychological, cultural, relational, individual factors are considered as risks for suicide that can lead a person to suicidal behavior (2) .
Understanding depression and risk for suicide, as well as the factors involved, is extremely important for studies related to the health of workers (9) .It is noteworthy that the prevalence of depression symptoms and suicide, which corresponds to the process and that the causes of death are caused by the victims themselves, is high among health professionals (1) .It should also be noted that the prevalence is influenced by environmental stress and work process, significantly interfering in the working lives of these professionals with an impact on their quality of life (1) .
Slowness in activities, disinterest, reduced energy, apathy, difficulty concentrating, recurrent negative thoughts, loss of capacity in planning and altering the perception of truth are evidence of human suffering that signal depression and possible suicide risk (6,9) .Among health workers, nurses are the group most prone to mental health problems, with depression and suicide risk among them, because they deal with human suffering, pain, joy, sadness and they need to offer help to those who need their care (1,9) .Other commonly found factors such as the difficult working conditions and lack of professional recognition can also be highlighted (5) .
Depression is one of the three most occurring conditions mentioned by nursing staff (6) , therefore, those responsible for health services should identify this problem early on, promote health at work, avoid sad and fatal outcomes, as well as the decrease or loss of care quality (1,5,10) .
The high rates of depression and risk for suicide are in contrast with the work performed by nursing professionals who are generally expected to provide care (5) , but also on the other hand, may need to be cared for.
So the question that guides this study is: What factors contribute to depression and suicide risk among nursing professionals?With the objective to discuss the factors associated with depression and risk of suicide among nursing professionals.

METHOD
This is an integrative review of the scientific literature (11) , which brought together research findings obtained from articles of online databases, developed in five stages: formulation of the problem, data collection, data evaluation, data analysis and interpretation, and presentation of results (12) .
The integrative review analyzes research that provides information for decision making and improvement of clinical practice, and also makes it possible to synthesize knowledge on a given subject as well as point out possible gaps in the studied literature (11) .
For the search of articles, the databases used were: Latin American and Caribbean Health Sciences (LILACS), the Nursing Database (BDENF -Base de Dados de Enfermagem), National Library of Medicine, USA (PubMed), Medical Literature Analysis and Retrieval System on-line (MEDLINE) and Scientific Electronic Library Online (SciELO), a broad online index of both national and international journals in health platforms, representing the majority of those articles which have an important impact in scientific literature.
Different search strategies were defined by using MeSH(Medical Subject Headings) and DeCS (Descriptors of Health Sciences) descriptors of the terms "nursing", "suicide" and"depression"in English and Portuguese, with the combination of the Boolean term "AND", adapted to each of the databases and in three stages: initially, only the descriptors "nurses" AND "suicide" were used; followed by "Nursing" AND "depression" descriptors; and finally, "Nursing" AND "suicide" AND "depression".For Figure 1, the English terms were used as a reference to facilitate the search in international databases.
Articles available electronically from January 2003 to August 2015 were included, as it is an updated and at the same time comprehensive time frame on the subject.
The selection by reading the titles was carried out first, then later by reading the abstracts and full articles, as shown in Figure 1.32 articles were chosen, of these, 20 were related to the objective of the study, by answering the guiding question and meeting the inclusion criteria.The five publications repeated in more than one database were only analyzed once.The literature search was conducted in Portuguese, Spanish and English.
The studies selected were then organized by a compilation of reviews/annotations, allowing for better organization of notes, and thereby establishing a very useful tool for later reference.Next, the articles were reread in full, in order to perform an interpretative analysis based on the guiding question and stated objectives.To facilitate data analysis, a summary chart (Chart 1) containing the variables was used.Topics of interest were: article title, year and country of publication, the type of study design, the sample containing the number of nurses surveyed or the number of articles, and the outcomes.

RESULTS
The publication countries of the studies read in full (excluding the repeated ones) that comprised the sample (n=20) were: Brazil, with eleven studies; Spain and Taiwan, two studies each; Australia, Canada, South Korea, the United States and Turkey, with one study each.Studies published in Brazil were all published in Portuguese; of these five, were also in English and two in Spanish.For those published in Spain, one was only in Spanish and one in English and Spanish, while those from Australia, Canada, South Korea, the United States and Turkey were only in English.
From the selected studies, sample characterization according to the year of publication with the corresponding quantitative studies is presented in Table 1.Table 1 shows the studies that comprise this integrative review in ascending order of year, country, title, and an outline of study type, sample and outcomes.As a result, we found: nine cross-sectional studies; seven quantitative studies; two literature revisions; one critical review; one qualitative study.

Year Country Title Study design/Sample Factors 2004 Brazil
Stress and psychosomatic repercussions in nursing workers from a university hospital (13) .
Conflicting relations in personal and family responsibilities; Overload; difficulty with suffering; death; lack of autonomy, and recognition; depression.

2007
Brazil Aspects associated to work-related depression on nursing staff (14) .
Graveyard shifts; interpersonal relationship; service overload; lack of autonomy; insecurity; conflict of interest and family income.

Brazil
Cognitive and emotional effects of occupational stress in nursing professionals (15) .
Conditions and work organization.

Turkey
Effects of Perceived Job Insecurity on Perceived Anxiety and Depression in Nurses (16) .
Burnout Syndrome, risk of suicide, depersonalization, low personal accomplishment.

Brazil
Evaluation of Quality of Life and Depression in Nursing Technicians and Nursing Assistants (5) .
Health problems and overnight shifts.
2011 Brazil Anxiety and Depression among Nursing Professionals who work in Surgical Units (9) .
Higher educational level, young adult, female, multiple jobs.

Brazil
Depression prevalence in Intensive Care Unit nursing workers: a study at hospitals in a northwestern city of São Paulo State (10) .
Graveyard/overnight shifts, double shifts and marital status.
2012 Brazil Depressive symptoms and suicidal ideation in nurses and physicians care hospital (1) .
Quantitative study, 100 doctors and nurses.
Work climate, ambiguous roles and the lack of clarity in relation to the tasks and expectations.

Taiwan
Stress, depression, and intention to leave among nurses in different medical units: Implications for healthcare management/ nursing practice (18) .
Cross-sectional study, 314 nurses.Marital status and complexity of care.
2012 USA Symptoms of Posttraumatic Stress Disorder Among Pediatric Acute Care Nurses (19) .
Higher rates of nightmares, severe anxiety, shortness of breath, severe pain, anxiety, depression and Burnout Syndrome.

South Korea
Perceived Stress and self-esteem Mediate the Effects of Work-related Stress on Depression (20) .
Quantitative study, 284 nurses.High levels of stress, decreased self-esteem.

Brazil
Illness and the use of psychoactive drugs among nursing workers at intensive care units (6) .
Lack of recognition, excessive workload and graveyard shifts.
2013 Brazil Depression, anxiety and social support in nursing professionals (21) .
Quantitative study, 400 nursing professionals.Limitations and every day challenges.
2013 Brazil Mental illness of workers in intensive care units (22) . Qualitative

DISCUSSION
By identifying the studies that referred to the factors which contribute to the onset of depression and risk of suicide among nursing professionals, it became evident in this integrative review that most (10 -50%) were published between the years 2012 and 2014, and the country with the largest amount of publication was Brazil with 11 (55%), followed by Spain with two (10%), Taiwan with two (10%), and Australia, Canada, South Korea, the United States and Turkey with one (5%) each.This suggests that researchers in Brazil have begun to show interest in understanding the implications of these two phenomena in the work context of nursing professionals.
Nursing is a profession that is susceptible to mental disorders, because nurses deal with life, pain and death of people under their care on a daily basis, and also the family's expectations (1,5,10,13,16,18,21,28) .Depression is one of the illnesses that most affects these professionals, causing damage to their work capacity and personal lives (1,(5)(6)10,(13)(14) . Because te state of depression is a predictor for increased risk of suicide (17,22) , nursing professionals exhibit higher risk for suicide (5) .
Table 2 summarizes the content in alphabetical order that has emerged from the analysis of the data found about the factors that contribute to Depression and influence Suicide Risk.

Work environment
The daily exposure of nurses to external physical and mental stimuli related to the complexity of the work, the absence of ideal conditions taking precautions when dealing with people with serious illnesses and the risk of death leads them to develop depression more easily (5,17,20,23) .Unhealthy working environments with poor conditions, coupled with the presence of internal conflicts and the pressure of the institution and patients' families maximize these professionals' risk for depression and suicide (5,10,17,25,27) .

Family conFlicts
Factors involving relationships were also identified as influential for symptoms of depression, particularly those associated with imbalances in the family lives of nursing professionals (1) .It has also been confirmed that family loss, absence of family and marital support increase the odds for suicide risk (2,10) .
It is worth mentioning that the operating mode of nursing professionals diminishes family contact, and the lack of this contact can lead to depression (10) .Tiredness and overwork compromise the dialogue of these professionals within the family (29) , as well as conflicts between having to meet the demands of nursing and reconciling with family responsibilities contribute to relationship wear (13) , along with having night and weekend shifts often taking the place of quality time spent with family (10) .
A study revealed that nursing professionals exhibit higher depression than medical professionals/doctors, and that a person with depression affects their social life and family (6) .
Although there are still no studies linking family conflicts in nursing and risk for suicide, a study (30) confirmed that family and marital conflicts are the third cause that appears on psychological autopsies of elderly who committed suicide.

interpersonal conFlicts in the Workplace
Interpersonal conflicts in the workplace are common and appeared as factors that lead to depression (22) .Nurses have mentioned the precariousness of interpersonal relationships, since health work is influenced and controlled by the relationships between people, which requires cohesion and collaborative participation (27,29) .Due to the relational aspects of nursing work, they can cause irritability, generate conflicts and interpersonal difficulties with the other team members, but also with managers, users and extend to their families (15,31) .
One of the measures to improve interpersonal relationships in the nursing work environment is access to relational technologies (29) .These can be promoted through dialogue, listening, bonding and acceptance, with the view that they raise the understanding of suffering, valuing experience and attention to the needs of the different people involved in the work process (32) .

marital status
Marital status and the position held by nursing professionals appeared as significant for the development of depression and stress (18) .This profession is made up mostly of women, and married women who deal with the working world in their daily lives, meet the demands of their children, their partner and their house, which increases the development of a stress framework that can culminate with depression (1,18) .Nurses working in medical clinics, especially those who are married, are susceptible to developing depression and quitting their job (18) , on top of damaging marital relations or delaying marriage.

stress
One study (23) revealed stress as a predictor of depression.Higher level of stress is associated with lower skill and safety to perform the work in the health professions.The highly complex activities and demand of nursing professionals also produces high levels of stress and consequently correlate with high levels of depression, for example nurses who work in psychiatric nursing, intensive care units and operating rooms (6,9,23) .
Work conditions have transformed the stress into something familiar and often normal, with implications on the health of nursing professionals, highlighting the need for the use of internal and external strategies to minimize stress through coping strategies to control, tolerate and reduce the effects of adverse stimuli (20,29,31,(33)(34) .

lack oF proFessional autonomy
Another contributing factor to mental illness concerns the lack of professional nursing autonomy (5) .The necessity to abide by the standards established by the hospital makes the nurse decrease the autonomy of the nursing team, since the control and power of the sector is not within their responsibility, thus affecting their activities and causing mental illnesses (13) .A study found that nurses restrict the autonomy of their subordinates because of the role they need to perform (13) .

insecurity in developing activities
A study showed that depression in nurses was also associated with insecurity in developing their work activities, which are characterized by high expectation standards, especially when they are highly complex or involve the possibility of patient death (14,22) .
At times, psychological distress has contributed to coping with professional demands through the desire to escape from responsibilities with passivity and pessimism, common in depression (14) .

young adults
A study (9) showed that depression affects younger groups of nursing professionals on a larger scale than those at an older age.The vulnerability of the first group could be linked to lack of experience in dealing with everyday situations in the workplace.This led to infer that maturity (cognitive, emotional and physical) generates security in the professional for resolving problems and facing adversities.

higher educational level
Nurses with higher education levels, such as a specialization, a master's or doctoral degree, are more affected by depression (9) , even though nurses are encouraged to expand their training constantly and acquiring new titular status will enable a salary increase and professional growth.These result in more requirements for job performance and consequently the acquisition of new responsibilities, generating overload and more chance for mental illness (10) .

graveyard/night shiFts
Working the night shift brings damage and risk to worker's health because it is exhausting and tiring (10,26) , which can worsen when the environment has critical working conditions, such as in the Intensive Care Unit, increasing the effects on the mental health of these workers (10) .
Night shifts, specifically, represent a risk factor for developing major depression (1) .A study (5) demonstrated that night shift workers have higher depression scores.Another study (6) stated that the night shift had the highest quantity of nursing professionals with psychiatric illness and that the more frequent and prolonged the night work was in the life of the nursing professional, the more labor compromise would be displayed.

Family income
Depression can also occur more frequently in nursing professionals with low family income.The lower the pay, the higher the prevalence of depression (6,14) .The association between family income and the increase in the level of depression was also observed in nursing students (14) .In contrast, another study (10) showed that the more the income increases, the more the number of employment relationships increases, which can be exhausting, causing impacts on the mental health of these workers.However, a study (9) showed high depression rates in professionals who have only one job, which may be related to low-income.

Work overload
Work overload is considered a contributing factor to increased emotional and physical stress, which can trigger several illnesses (6,10,13) .It also leads to mental illness and is considered a triggering factor of depression (1,9,27) .Studies (6,10,19) revealed that work overload produced physical and psychological wear and tear on the nursing staff in the ICU, and among the main triggering factors found were nightmares, depression, severe anxiety and panic, thereby leading to Burnout Syndrome.Another study stated that overload and low wages generate excessive work hours and physical and emotional exhaustion among nurses (27) .
Studies (14,22,27) also point out that work overload arises from a lack of professionals, especially on holidays; coworkers who do not complete all tasks and cause excessive burden for the following shift; conflicts of scale/shifts, resulting in dissatisfaction and the intention to abandon employment; and larger amounts of hospitalized patients.
It is worth noting that the work environment, family and interpersonal conflicts in the workplace, as well as marital status, lack of professional autonomy, insecurity in developing activities, age, higher education level, night shift, family income and work overload appeared as factors with significant influence for changes in mental health causing depression disorders.

Factors contributing to suicide risk
Studies (1,17,22,(24)(25)(29)(30)(35)(36)(37)(38) revealed that nurses have a high risk for suicide. Records indicte that in some countries, the risk of suicide among nurses is higher than in the general population; for example, in Denmark, Australia, and New Zealand, while Norway has a higher prevalence of suicide among nurses than other health professionals (25) .Risk factors can be: depression, low self-fulfillment and Burnout Syndrome.The risk of suicide was positively and significantly correlated with depression (17,25) .Studies (1,25) showed that the prevalence of depression symptoms is more pronounced among nursing professionals.Using the known diagnostic reconstruction technique (psychological autopsy), it was noted that psychiatric disorder is one of the biggest risk factors for suicide, and suicidal behavior is quite common among most groups of people with psychiatric diagnoses, and major depression disorder is most prevalent among suicide victims (1,30,(35)(36) .

loW personal FulFilment
Studies (1,17) revealed that there is a correlation between risk of suicide and self-fulfillment.The less nurses succeed in the exercise of their profession, the more they appear to have negative responses to themselves and their work; symptoms such as low self-esteem, irritability, decreased interest in sexual activity, lack of appetite, interpersonal relationship avoidance with colleagues, self-punitive feelings, low productivity, lack of interest in work and depression are very likely to increase the risk of suicide (1,17,(35)(36) .In contrast, there was a significant negative correlation between risk for suicide with high self-esteem and personal fulfillment (17) .

Burnout syndrome
Another predictor for the risk of suicide is emotional exhaustion, which is characterized by loss of energy, wear, exhaustion and fatigue; an emotional state closely related to components of depression, consistent with the principle component of Burnout implicated by suicide (17,25,29) .Among the many common symptoms of this illness, harmful acts or suicide appeared as one of the most alarming (22) .In the case of nurses, in general, only one study (17) showed relatively low levels of Burnout and suicide risk among these professionals compared to other studies.However, it should be noted that in the same study there was a high level of emotional exhaustion, high depersonalization, and low personal fulfilment, features that may lead to Burnout Syndrome symptoms and consequently risk of suicide (17) .
Also, factors such as a lack of knowledge and motivation for career development are related to Burnout Syndrome (29) .Professionals expect recognition from those who are close to them in their daily practice, but it does not always happen, possibly leading to feelings of incompetence, failure, despair, helplessness and suicidal tendencies (22,25) .This research revealed that the risk of suicide among nurses is associated with the presence of factors such as depression, low self-accomplishment and Burnout Syndrome.Other studies (37)(38) report that it is difficult to prevent suicide, given the complexity of discovering the imminent risk of suicidal behavior; however, they may contribute to its prevention and risk evaluation, for the identification of risk factors through the use of strategies which include: restriction on highly lethal means, use of tracking methods and identification of those at risk, suicide risk management, education of the general population, coverage by responsible media, diagnosis and effective treatments, continuing education of health teams for intervening in a multimodal and interdisciplinary manner (38) .

CONCLUSION
This integrative review showed that studies on depression and suicide risk among nursing professionals have been published mostly between the years 2012 and 2014, with significant production in Brazil.
Risk factors for depression among nursing professionals concerning work, human relationships and personal characteristics, and the risk of suicide associated with the presence of mental disorders and the professional environment have been identified.It has been found that depression of these professionals is influenced by factors such as the work environment, family and interpersonal conflicts among workers, marital status, stress, lack of professional autonomy, insecurity in developing activities, age, educational level, night shifts, family income, and work overload.This study also demonstrated that depression, Burnout Syndrome and low personal accomplishment contribute to suicide risk in this category of professionals.
Therefore, it was identified that nursing professionals who perform activities in unhealthy environments with conflicting interpersonal and/or family relationships and in the workplace, married, with high levels of stress, a lack of professional autonomy, with insecurity to develop their work activities, younger, better educated, working on night shifts, with low family income, several employment relationships and work overload are more vulnerable to developing depression.Also, there is a risk for suicide in those who already have symptoms of depression and high levels of emotional exhaustion, high depersonalization and low personal accomplishment; characteristics of Burnout Syndrome.
It is worth mentioning that all the factors directly related to depression may also be indirectly related to the risk of suicide, because depression is considered a predictor of it.All of these factors alone or combined can influence the health care services provided.
It is important to consider health and quality of life of nursing professionals given that their professional practice occurs in complex realities, with the most diverse human relationships, having to routinely deal with different requirements, being faced with factors that can produce risk for depression and suicide, and that contribute to the illness and compromise the delivery of care.
Nursing professionals must be understood not only as a health worker, but they should also be seen as a person who may suffer harm to their own health.Thus, the aim of this study was to draw attention to the seriousness of the risks involved, both in their work and in their personal lives for developing mental disorders, which is often overlooked, even by the professionals themselves.Evidence reinforces the need to identify early risk factors for depression and suicide in workers in this occupational category, as well as elements so that nurses can recognize them and evaluate them in their team.
From the analysis of the studies, it became clear that there is alack of research/studies aimed at identifying, diagnosing and intervening on these factors and with this specific audience in order to prevent progression to severe depression conditions, and subsequently to a high risk of suicide.
Therefore, this study may have implications for the prevention, early detection, treatment and psychosocial rehabilitation of nursing professionals, who face factors related to depression and risk for suicide in their daily work.

Figure 1 -
Figure 1 -Selection of articles by groups of descriptors in the database.

Table 2 -
Content that has arisen.