DEPRESSION AMONG NURSING STUDENTS ASSOCIATED TO THEIR SELF-ESTEEM, HEALTH PERCEPTION AND INTEREST IN MENTAL HEALTH

Objetivou-se identificar a relação da presença de depressão entre acadêmicos de enfermagem com sua auto-estima, percepção da saúde física e interesse por saúde mental. Metodologia: pesquisa realizada em sala de aula, entre 224 estudantes de enfermagem. Utilizou-se questionário de Conhecimento e Pontos de Vista sobre depressão, Inventário de Beck, Escala de Auto-estima e informações sobre saúde e Qualidade de vida. Investigou-se dados sociodemográficos, clínicos e interesse do aluno pela saúde mental. O projeto foi aprovado por Comitê de Ética. Resultados: a depressão está presente entre estudantes de enfermagem em níveis esperados para a população. Os resultados, avaliados estatisticamente, evidenciaram correlação entre percepção da saúde física (ruim e média), interesse e freqüência a cursos na área, concluindo-se que há maiores chances de presença de depressão entre esses estudantes de enfermagem.


INTRODUCTION
Depression is a universal mental disorder, whose main problem is the change in mood.Mood changes have a global repercussion on the activity of the affected person (1)   .
Depressive episodes are disabling, tend to be recurrent and, less often, are chronic without symptom remission.Every year, 17 million Americans are affected by depression, causing great suffering to patients, family members and people living amongst them.It is estimated that, by 2020, depression will be the main cause of disability in developing countries (2)(3) .
A study looked at psychiatric hospitalizations in Ribeirão Preto, through the Single Health System (SHS), and showed that mood disorders were the second cause of hospitalizations from 1998 to 2002 (4)   .
Depression is a syndrome characterized by a group of symptoms with changes in one's mood (sadness, guilt), behavior (isolation), thought and perception patterns (less concentration, less selfesteem), with physical complaints (sleep, hunger, sex) and high risk of suicide.
Depression occurs with people of both genders, any age or social class.However, the first episode usually occurs during adolescence and early adulthood, and it is more common among women, especially due to hormone changes (1-2)   .Recent studies have addressed genetics, molecular biology, as well as image, hormone and metabolism research with a view to finding etiologic explanations for this pathology (2,5) .
The depressive state disturbs the way people evaluate and see themselves.It changes the perception they have of others and the world (2) , and affects their personal esteem.Self-esteem levels are personality constructs that result from intra and interpersonal relationships.They affect people's attitudes in their school activities, at work and in every other daily activity (6-7)   .
The scientific community's interest in mood disorders has increased, due to their growing prevalence, associated with improved diagnosis, larger medication offer and knowledge on advancements in neurobiology research.
Health professionals' mental health, especially that of nurses, is subject to strong and controversial feelings.It has been the object of studies due to occupational stress, the ambiguities of the profession, and the importance of these professionals' biopsychological integrity, as they deal with human suffering (8)(9)(10) .Nursing students begin to experience these ambiguities and demands as undergraduates (7,11) .
Knowing that depression can be more common among women living stressful situations in the first years of their adult life, that most nursing professionals are women, and that working in the health area is relatively stressful, since it means dealing with suffering lives, the concern about nursing students having depression is fundamental (7,11)   .

OBJECTIVE
To identify depression among nursing students and its relationship with the students' selfesteem, their perception of physical health, and their interest in mental health.-Inventory on Knowledge about Depression: contains 12 situations that assess one's knowledge about the disease and its treatments, with five answer choices for each statement (12) .

METHODOLOGY
-Scale for Opinion about Depression: consists of ten statements ranging from 0 (disagree) to 9 (agree).It looks at the meaning of depression, the interest in this topic and professional conduct (12)   .
-Beck's Inventory: it was designed in 1960 and translated and validated to be used in Brazil in 1998 (13- 14) .It consists of 21 statements that identify the intensity of depression signs.
-Self-esteem Scale: designed by Janis & Field, it contains 23 items to determine self-esteem levels.It has been translated and adapted to the Portuguese language (15) .
Physical health self-evaluation, using a clinical perception question from the header of the Quality of Life Assessment Scale -WHOQOL-BREF.
These instruments, identified by codes, also contained sociodemographic data (gender, age, ethnics, marital status), clinical data (physical and mental health perception) and the nursing students' reports on their interest in the mental health area as well as their course attendance.

Data collection
Performed in the classroom where students met for school activities.The students received explanations about the study objectives, their right to decline participation and how to complete the forms.
It was also clarified that cases with depression signs would be contacted and forwarded.

Ethics
The project was approved by the EERP/USP Ethics Committee (Review number 0335/2003.6).All participants provided written consent.

Data Analysis
The results were grouped in calculation tables and subject to statistical analysis with STATA.Fisher's exact test was applied in case there were associations between the variables (bivariate analysis).
For the joint analysis of the possible effect of independent variables on depression, multivariate analysis was applied.The chosen technique was backwards stepwise regression.The model initiates with all present variables and at each step the variable that contributes less to the explanation of the model is eliminated.Those that are significant at 5% are maintained.
The Odds-Ratio was chosen as the element for comparison.For every test, the probability of a primary error (Alpha) was fixed at 5%.
The results were discussed based on literature on the theme.

RESULTS AND DISCUSSION
Participants were 224 students from the first three years of the Nursing Bachelor's course (73, and 76, respectively), with the following profile: most students were women (95%); ages ranged between 17 and 44 years, with a majority between 20 and years (79%); almost all were single (95%), 4.5% were married, and 0.4% were separated (Table 1).students (11) .Furthermore, only 15.2% were younger than 20 years and the largest group (79%) was between 20 and 25 years old.It is observed that more men and older people, either married or not, have enrolled in the nursing course.
When observing these data in the three groups of students, it is verified that, in the first year, 8.2% of the students are 25 years or older, with 37% younger than 20 years, against 1.3% younger than 20 years in the third year.What is emphasized here is the 8.2% older than 25 years in the first year.This group was the most heterogeneous in terms of age.

COMPARING DEPRESSION WITH PERCEPTIONS OF PHYSICAL HEALTH, SELF-ESTEEM, KNOWLEDGE AND INTEREST IN MENTAL HEALTH
Based on the data obtained through the various instruments used, and due to their multiplicity, the authors have published, in another study, part of the results of this same research, focused on the analysis between depression and self-esteem (7) .
Regarding the identification of depression among the 224 students, there was one case of serious depression, 14 moderate depression, 28 mild depression, and 181 (80.8%) without signs of depression.
Since the study sample was neither clinical nor suspect, scores < 15 were used to determine cases without depression, 15 to 20 for dysphoria/mild depression, 20 to 30 for moderate depression, and > 30 for serious depression, as recommended to assess the general population (12-13,16-18)   .
It is worth emphasizing that the rates found in the study sample for mild (12.5%) and moderate and serious (6.9%) depression are close to those found in the general population.The identified cases (6.9%) were contacted, welcomed, instructed and appropriately forwarded.
When analyzing the statements on the Beck Inventory, which addressed depression signs, it was observed that 19.2% (43) of subjects presented some degree of depression, 12.5% (28) of whom presented dysphoria, 6.3% (14) moderate depression, and one (0.4%) presented serious depression.
As to the nursing students' self-esteem, it was observed that 17% had high levels and most (63.4%)presented medium levels of personal esteem.
As to the association between self-esteem levels and depression, it was observed that none of those with high self-esteem levels presented any depression signs and, inversely, that all participants with signs of moderate or serious depression had medium self-esteem levels (7) .
Although this study did not aim to discuss quality of life indicators, included in the WHOQOL Quality of Life Scale, a positive correlation was observed between the students' self-evaluation of their physical and mental health and the presence of depression (Table 2).In the bivariate analysis of health (physical and mental) perception associated to depression, it is observed that students with depression consider that their mental health is not good, but especially consider their physical health as bad or average.In this sense, it is remarkable that two students without depression consider their physical health terrible, while one student with depression considers it very good, both with average self-esteem.
Naturally, depressed individuals perceive their emotional condition.In fact, they also find it easier to recognize their sleep, eating, and sex difficulties.However, these people do not associate the somatic symptoms with their depressive state.Therefore, they seek formal or alternative health services or turn to self-medication or isolation due to these difficulties (1-3,5,17-18)   .
Regarding the Knowledge Scale about depression, it was observed that the students, in general, have good knowledge about depression.They know it is a common disease that can cause personal as well as social complications.This has also been observed in previous studies (17-18)   .According to studies with the same subjects (7) and studies with other students and nurses (17)(18) , a lack of precise information is observed about the criteria used to identify depression, pharmacological effects and interactions, as well as about other therapeutic resources.
The scale for assessing the students' opinion about depression classified the scores as low (0 to 2.9), average (3 to 6) and high (6.1 to 9).The results show that 85.3%, 93.7% and 31.3%, respectively, have points of view that agree with the test, that is, they know how to identify depressed patients; Furthermore, they agree that nurses can be the first element in detecting and managing depression cases.This opinion test also identified the students' interest in mental health and their participation in extracurricular courses in that field.Previous studies have shown lack of interest and participation in courses among nurses (17) , against strong interest among bachelor's students (18) .
As previously assessed, a certain association is observed between time since graduation and interest in mental health.Until recently, the mental patient was an issue and a competence of that specialty and institutionalization in closed psychiatric hospitals; therefore, other health professionals were not concerned with improving or updating the knowledge they acquired in their professional development.
However, there have been changes in this situation due to the psychiatric reform movement, and because of the reorganization in the Brazilian health system (SHS), offering primary health care with Family Health Programs and the BHU (Basic Health Units), secondary services (outpatient care, psychosocial care groups and centers) and hospitalization services (emergency, hospitals and clinics) and psychosocial rehabilitation.
Considering the current health care scenario and the data found in the present study, an attempt was made to establish correlations between some significant variables and the presence of depression, through bivariate analysis, as observed in Table 3.
It is observed that some variables showed significant results when compared to the presence of depression.
The relationship between depression and selfesteem had already been evidenced in a previous study (7) and is confirmed through bivariate analysis with p<0.005 (Table 3).For a joint appreciation of the effects each variable exerts on the dependent variable "depression" in the presence of the other variables, multivariate analysis was performed, using logistic regression.This analysis, with adjusted odds ratio and respective confidence intervals, permit to assess the associations between the variables "perception of physical health", "reporting interest in mental health", attending courses in this field" with the presence of depression.Table 4 lists the variables that were maintained in the model, with the respective odds ratio and P values.Some live in conformity with their poor quality of life, and hence increase their isolation, interest in bad news, tragedies.They also learn to accept the terrible conditions of their physical health (sleeping badly, changes in weight and appearance, and having no interest in sex) (1)(2)12) .
Although the students report their interest in mental health, and although those participants who most attended courses were part of the group with depression signs, the authors believe that there is no relationship between the cause and effect of participating in courses and having depression.However, it is suggested that, in their silent suffering, they search for answers to their symptoms in these courses.
Many depressed people seek the help of clinical physicians, priests or religious mentors.In general, patients get in touch with various health care professionals.They ask indirect, diffused, incomplete questions, testing these professions' point of view.
They search for information on the internet, books, take courses or choose nursing, psychology, or social work professions when they wish to find answers to their hidden anxiety.
Since depressed people do not ask straightforward questions, they never find effective answers, so they continue searching when they do not find the appropriate pathway to overcome their problem.
The present study results offer important contributions, in line with the World Federation for Mental Health's proposal for the 2006 World Mental Health Day, which addressed awareness about risks of developing mental illnesses and suicide (19) .

CONCLUSIONS
Depression is present among nursing students at the same levels as expected for the non-diagnosed population.Having depression implies associated medium levels of self-esteem.In addition to the characterized emotional state of depression, depressed students notice physical health problems, although they do not associate them with this condition.
There was a tendency towards greater interest in the theme and a greater search for mental health courses among students with some sign of depression.
The identified cases were contacted, instructed and/or forwarded.
Finally, special attention should be given to the changes in the depressive state among nursing students and their search for frequent clinical services and extra-class activity in the field should be observed.

Table 1 -
Distribution of sociodemographic variables

Table 2 -
Bivariate analysis results of the students'

Table 3 -
Distribution of bivariate analysis results

Table 4 -
Logistic regression results: Adjusted odds ratio with the respective confidence intervals