Antidepressants : Knowledge and Use Among Nursing Students

This study examined the knowledge of nursing students in regard to using antidepressant medication and proposes actions such that nurses contribute to a safe and effective antidepressant therapy. This cross-sectional and descriptive study was conducted in a public nursing school in the state of São Paulo, Brazil, between March and November 2008. Fifty-two (19%) out of the 273 participants were using or had used antidepressants. Instruction concerning the use of antidepressants was provided by physicians. Even after receiving instruction concerning the antidepressant treatment before its administration, the majority of users (χ1=0.07, p> 0.05) still had doubts about its use. Fluoxetine was the most prevalent antidepressant. Actions to improve knowledge concerning the use of antidepressant medications, their side and therapeutic effects, seem to be necessary and relevant.


Introduction
Depression is a chronic and recurrent disorder characterized by one or more depressive events with at least two weeks of depressive mood or loss of interest in most activities, accompanied by at least four additional depressive symptoms (1) .These symptoms include: persistent pessimism, guilt, difficulty in concentrating, hopelessness, decreased sexual desire, increased irritability, insomnia, and appetite loss (1)(2) .It is known that the prevalence of depression among people younger than 20 years of age has increased worldwide (2) .It is estimated that the prevalence of depression among the young population might reach 8.3% (3) and that the frequency of depression is higher among students than in the population in general (4)(5) .Therefore, university students have been a target of studies addressing mental disorders.One study carried out with nursing students Istilli PT, Miasso AI, Padovan CM, Crippa JA, Tirapelli CR.
shows that 55% of students present a high level of depressive symptomatology (6) .In accord with this finding, one recent study verified that 41.4% of nursing students presented levels of depression that varied from light to severe (7) .
Two types of treatment have been used to treat this population: psychotherapy and therapy with antidepressant medications.However, the number of antidepressants prescribed to young individuals has increased in recent years (2) .The treatment of depression includes medications that belong to one of the following classes: tricyclic (TCAs), serotonin-specific reuptake inhibitor (SSRIs), Serotonin-norepinephrine reuptake inhibitors (SNRIs), Monoamine oxidase inhibitors (MAOIs) and atypical antidepressant (2) .Among the different classes of antidepressant medication, the SSRIs are the most commonly used by young individuals with depression due to their profile with less side-effects (2) .Several studies stress that health professionals play an important role in treatment adherence.These studies show that one of the key factors influencing treatment adherence is how much patients rely on the prescription, on the health team and/ or the physician (8)(9) .
Nurses have various functions and the most traditional one is the technical function in which the responsibility to administer medication stands out.This responsibility includes: pharmacological knowledge concerning medications; planning inventory and storage; educating employees, patients and family members; assessing patients before and after administering medication; preparing and administering medication; assessing and promoting therapeutic effects; taking action to reduce adverse effects and adverse interactions and controlling toxicity (10)(11) .Considering the increased prevalence of depression among the youth and the fact there is a considerable incidence of this disorder among university students, this study evaluated the opinion of antidepressant users concerning instruction about the use of medication, verified the knowledge of users concerning antidepressants and characterized the pattern of consumption of antidepressants.Additionally, based on the main identified issues, actions are proposed to nursing professionals so that therapy with antidepressant medication is carried out in a safe and effective manner.and reason for taking the medication).A structured selfreport technique through a questionnaire was used to collect data.Information was recorded by the individuals themselves (self-reported) but they had the opportunity to clarify their doubts with the interviewer (12) .Interviewees were not obliged to fill in the questionnaire and could return it blank.

Method
A quantitative approach was used for data analysis.
After coding each of the variables, a dictionary was developed to construct a database in Excel (Windows ® ).

Results
The number of participants who were using or had already used antidepressants was 52 students, 19% of 273 students participating in the study.Of the 52 participant users of antidepressant, 25 were from the Rev. Latino-Am.Enfermagem 2010 May-Jun; 18(3):421-8.
bachelor's degree program and 27 from the teaching diploma degree.The participants' socioeconomic data are presented in Table 1.We observed in Table 3, which presents the knowledge of participants concerning the actions of antidepressants that, 44.2% of the participants did not know when the antidepressant would start to act.

Variables
Additionally, most of the antidepressant users believed these medications cause tolerance and dependency issues.We also observed that the participants did not increase the dosage of the medication without medical consent.However, statistically significant differences .49; p>0.05) were not found between the number of participants who interrupted the treatment without consulting their physicians and those who did not.2).Most of the participants (98.1 %) considered that the instruction provided was important (χ 2 1 =48.10;p<0.05) in increasing , safety, effectiveness of and trust in the therapy, to minimize its side effects and drug interactions.Even though instruction was provided before antidepressants were administered, no significant differences (χ 2 1 =0.07; p>0.05) were found between users (51.9%) who presented doubts and those who (48.9%) did not (Table 2).Istilli PT, Miasso AI, Padovan CM, Crippa JA, Tirapelli CR. were also mentioned.
A positive correlation was found between doubts concerning the treatment and the fact that participants interrupted the treatment without consulting their physicians and also a positive correlation between the use of medications and side effects.However, positive correlations were not found between doubts concerning the treatment and information about the antidepressant or between the period for antidepressant to start acting and interruption of treatment without the physician's consent.Likewise, positive correlation was not found between the presence of side effects and increasing the dosage without first consulting the physician (Table 4).

Discussion
The use of antidepressants by young individuals in general can reach 8.3% (3) and according to this study's results, the use of these medications is higher among nursing students, since 19% of the participants use antidepressants.These results are in agreement with the literature, which reports a higher prevalence of depression among university students, whereas 40% to 55% of nursing students present high levels of depressive symptomatology (6)(7) .However, results similar to this study should be carefully interpreted since most of the studied sample was female and depression and anxiety (conditions that require the prescription of AD) are known to have a higher prevalence among women.
The majority of antidepressant users in this study had medical follow-up and followed the medical prescription, which shows they trusted the treatment and instruction provided by the physician.This observation is corroborated by the fact that there was no positive correlation between side effects and increasing dosage without previously asking the physician.Several studies state that health professionals play a central role in treatment adherence.These studies show that one of the key factors influencing treatment adherence is the trust patients have in the prescription, the health team and the physician (8)(9) .This study confirms these data when it reveals that most of the users believe that the instruction provided by health professionals on the appropriate use of the medication increases the therapy's safety and trustworthiness.Nurses have an essential role in educating and establishing bonds with patients in order to promote a trust relationship, and increase the therapy's safety and effectiveness (10) .Even with all this responsibility in the process of implementing and maintaining the therapy, the participation of nurses was not observed in the education process provided before the administration of the medication; were aware that the medication has to be gradually interrupted.However, it is important to highlight that even though almost all participants received instruction concerning the medications' uses, many of them had doubts and misconceptions about these medications.
From this perspective, a positive correlation between doubts concerning the antidepressant treatment and the fact that patients interrupted treatment without consulting their physicians was found.This is an important aspect because interrupting treatment without consulting the physician can lead to the reappearance of depressive symptoms (10) .The fact that many of the study's participants did not know there is a latent period greater than two weeks for the medication to cause any effect can directly interfere in the therapy.The reason is that these patients might interrupt the treatment due to not observing an immediate improvement in their condition or they may increase the medication dosage in order to observe the desired effects.Moreover, educating patients regarding the need to wait a period Istilli PT, Miasso AI, Padovan CM, Crippa JA, Tirapelli CR.
to observe the first effects of antidepressant medications does not generate unfounded expectations, which can increase treatment adherence (10) .We also observed that most antidepressant users believe that the medication can cause tolerance and/or dependency, which are not actually associated with this type of medication.This is an alarming finding since most of the students who use antidepressants already have knowledge about the pharmacological actions of these medications.Lack of knowledge concerning the pharmacological actions of these medications was previously reported and was attributed to a gap between theory and professional practice, a fact that hinders understanding and implementation of pharmacological principles in daily practice (13) .
Prescribing multiple medications requires constant attention and care because there is a positive correlation between the use of other medications and side effects.
Most of the participants in this study reported the use of other medications concomitantly with antidepressants.
Prescribing multiple medications requires the review of medications in use and extensive knowledge of them, in order to minimize substances used, monitoring and taking into account side effects and toxic effects (14) .
The foundation of identifying and understanding drug interactions is based on physiology, physiopathology, drugs mechanisms of action, but also on care focused on the clinical observation of patients, characterizing symptoms and their development over the treatment course.
Fluoxetine was the most frequently used antidepressant and some users concomitantly use it with other antidepressants and diazepam, an association potentially dangerous since diazepam is a substrate of the enzyme CYP 2C19 (15) , which promotes hepatic metabolism of this compound.Fluoxetine can increase plasma concentrations of diazepam by inhibiting its metabolism (16) and lead to psychomotor and attention impairment.The set of presented data shows that there are doubts concerning antidepressant therapy.
Due to such a situation, nursing actions should include the development of an educational plan to be provided before the administration of medication, in order to provide information about the time it takes to act and potential side effects associated with its use.Nurses should also provide a written list of the main medications that interact with antidepressants and instruct patients never to use additional medication without the previous approval of their physicians.These actions increase treatment adherence because they do not lead patients to create unfounded expectations in relation to the antidepressant treatment (10) .
Recent studies show there is a high incidence of depression (17) and consumption of psychotropic medication among nursing students (18) .This study corroborates these data and also shows that there is a lack of knowledge concerning how these medications act among students who use them.

Conclusions
In total, 19% of the interviewed nursing students were using or had already used antidepressants: fluoxetine was the most frequently prescribed antidepressant.
Nurses did not take part in the education of this study's population before medication was administered; that role This cross-sectional and descriptive study was carried out in a public nursing school in the state of São Paulo between March and November 2008.This institution had, at the time of data collection, four classes (with 80 students each) in the bachelor's program and three classes (with 50 students each) in the teaching diploma program, totaling 470 students.Of the 390 students contacted, 273 agreed to participate in the study and composed the study's sample; 52 of these reported the use of antidepressant medication.Data were collected through a closed questionnaire composed of four parts.The 1 st part collected the subjects' identification data; the 2 nd part asked the opinion of antidepressant users concerning instruction provided about using the medication; the 3 rd part collected data related to the knowledge of users concerning the antidepressant medication, and the last part characterized the pattern of consumption of antidepressants (type of antidepressant, dosage, frequency of consumption, medical follow-up, Data were statistically analyzed in SPSS version 15.0.Analysis of data correlation was carried out with Person's correlation coefficient test.Statistical associations between variables were investigated through the Chi-square test (χ 2 ), and hypothesis of association was accepted when p<0.05.Statistical correlations were investigated between the different variables that composed the questionnaire, which are: education concerning side effects, drug interactions, time required for the antidepressant to start acting, type of education provided (who provided the instruction -appropriate or not) and doubts regarding its use.The project was approved by the Committee of Ethics Research Involving Human Subjects at the University of São Paulo at Ribeirão Preto, College of Nursing (Protocol 0843/2007).The participants signed free and informed consent forms in compliance with the resolution of the National Council of Health (CNS 196/96).
this responsibility was restricted almost exclusively to the physician.One cannot explain why nurses did not provide instruction concerning the use of antidepressant medication to these individuals based on the study's data.However, it might have occurred due to the fact that most cases of depression and anxiety (diagnoses that require antidepressant prescriptions) are focused on a physician-patient relationship, which usually occurs at an outpatient level.Nurses' participation more frequently occurs in hospitalization or semi-hospitalized situations, in services in which a multidisciplinary participation is more appreciated.Medical education concerning the medication's dosage and up to the final stage of treatment was efficient because most of the participants was restricted to physicians.Most of the antidepressant users believe that the instruction provided by the health professional regarding the appropriate use of medication increases trust in and safety of therapy.Despite the education provided, a large percentage of users still had doubts about the use of antidepressants, especially in relation to the period it takes to start acting, potential drug interactions, and whether it causes tolerance and/or dependency.It is important to highlight that this study's sample is composed of nursing students who should be prepared to educate patients in the use of antidepressants.The reason for such a lack of knowledge is not clear, but it might be related to a gap between theory and professional practice.Future actions with a view to improve the knowledge of nurses-to-be concerning the use, side effects and therapeutic effects of antidepressant medication seem to be particularly needed and relevant.

Table 1 -
Frequency and percentage of socioeconomic characteristics of students who were using or had used antidepressants.Ribeirão Preto, Brazil 2008

Table 2 -
Distribution of the study participants according to their opinion regarding the importance of treatment instruction.Ribeirão Preto, Brazil, 2008

Table 3 -
Distribution of the study's participants

Table 4 -
Correlation matrix of variables