Chapter 9. Summary

Depression is one of the ten most common diagnoses applied to working-aged clients of health care centres and the most common mental health diagnosis (Poutanen 1996). The number of disability pensions granted for major depression quadrupled in Finland during 1987-1995 (Salminen et al. 1997). About 4 % of children and 20-40 % of adolescents suffer from depression at least occasionally (Laukkanen 1993, Moilanen 1995), and depression is the most common psychic disorder among the elderly (Hughes 1992, Pahkala 1995). Slightly more than half of the health care centre visits by depressed clients are managed by nurses.There are, however, hardly any studies available on nurses’ experiences and notions of depression and its treatment in Finland.

The purpose of this study was to describe and analyse the notions that nurses working in primary health care had about their own and their working community’s experiences of depression and ability to recognise and manage depression, and to evaluate the impacts of a three-day training course on the nurses’ working practices and subjective skills. Two methodologically different substudies were carried out. The first substudy was part of a STAKES (National Research and Development Centre for Welfare and Health) project on the diagnosis and treatment of depression. The nurses working in four health care centres (n=281) constituted the study group, while the physicians employed in the same centres served as controls (n=58). The research intervention was a three-day training course on the recognition and treatment of depression, and the data were collected through three inquiries. The first questionnaire concerning the subjects’ baseline abilities to identify and treat depression was filled in before the training course and the final questionnaire six months after the training course, while the feedback questionnaire was filled in right after the training course. The response rate among the nurses was 68 % at the baseline, 48 % after the training course and 30 % six months later.

For the other subproject, 13 nurses with different duties in five health care centres different than in the first substudy were interviewed. A phenomenographic analysis of the interview material yielded categories of the nurses’ notions of depression. The categorisation further resulted in a typology of five treatment orientations, which reflected the nurses’ holistic approaches to depression and its management. The key themes in the subprojects were the prevalence and recognition of depression, the typical symptoms of depression, the abilities of the nurses and their working communities to treat depressed patients, the management of depression, multiprofessional cooperation, and the nurses’ personal experiences of depression.

All nurses encountered depressed patients in their work, but younger nurses tended to report higher frequencies. According to the nurses, depressed patients most commonly consulted the occupational health care service or the on-duty nurse. They found depression hardest to recognise in children, adolescents and elderly clients. The following key symptoms of depression were mentioned: sleep disorders, fatigue, thoughts of death, low spirits and a lack of joy in life. Vague somatic symptoms and an inability to take care of oneself were also said to be signs of depression. Despite this, the nurses stressed the importance of examining all somatic symptoms before making a diagnosis of depression. The following causes of depression were reported: concrete or mental losses, life crises and the tendency of females to respond to stressful life situations through mood changes. Both the nurses and the physicians pointed out that the most problematic aspects of treatment were the lack of resources for psychotherapy and the difficulty of including the family members when necessary. According to the nurses, the physicians did not have enough time for depressed patients, were too cautious and preferred medication to other modes of therapy. None of the nurses considered medication the treatment of choice for depression. Most of them considered individual psychotherapy the best approach, but also appreciated family therapy. The nurses, however, had vague or even mystified notions of what therapy actually is. They pointed out that the three-day training course gave them information about mental health work and contacts with some people doing this work. After the training course, the nurses’ notions about their own and their community’s abilities to manage depressed patients were more optimistic. The physicians estimated their abilities to help depressed patients as better than the nurses both before and after the training. Cooperation between health care workers in the management of depressive patients both within the health care centre and with outsiders was reported to be insignificant by the nurses and almost nonexistent by the physicians both before and after the training.

The analysis of the interview material revealed five different treatment orientations: the rational motivator, the friendly listener, the conscientious delegator, the independent intervenor and the empathetic escort. The discriminating factors were the nurses’ attitudes to depression as the clients’ or their own experience and their notions of their own and their working community’s ways and skills of managing depression. The differences were not related to education or job description, but rather to the nurses’ working and life situations and their individual attitudes towards depression. The nurses with one of the first three orientations usually immediately referred the depressed patient to either a physician or a mental health worker. They seldom mentioned their suspicion of depression, but rather waited for the patient to bring up the topic. They considered the treatment of depression a minor part of their work and only tended to make sure that the patient would be adequately treated elsewhere. The nurses with the last two types of orientation, however, were confident of their own ability to help depressed patients and wanted to do as much as possible for them. When they detected depression, they were active and talked to the patient about the matter, helping him or her to find suitable further treatment. Some of them wanted to treat mild depressions themselves, or at least to take part in the patient’s process even when the actual treatment was given elsewhere. They were interested in mental health work.

All of the interviewed nurses considered it their duty to help depressive patients and said that it was important to do“even something little”, such as arrange concrete help, listen to the patient for a while, provide treatment elsewhere or continue discussions with the patient. Despite this, they frequently underestimated the significance of their contribution and considered themselves unable to “really” treat depression. They said that their own life experience helped them to understand the clients’ problems and underlined the need to respect the clients and to take them seriously in interaction. The nurses said their nursing education had hardly prepared them at all to encounter mental health problems. Most nurses said that their possibilities to help depressed patients were inadequate due to their lack of time and strict schedules: they had to do the screening and other tasks traditionally assigned to nurses and to focus on somatic nursing or health care.

According to the findings, the nurses were aware of the high frequency of depression among their clients and able to identify both psychic and physical symptoms of depression. They were able and motivated to learn new ways of helping depressed patients and also to treat them either independently or as part of a team. The practical realities, however, limited most nurses’ possibilities to help the clients they considered depressive: the time, money and human resources available for the care of depressive patients and the possibilities for multiprofessional cooperation are scant. None of the nurses interviewed had mentoring services available. Nor did they get much feedback on even their successful interventions in the management of mental health problems or other disorders. The locally sectorised model of primary care, which is gaining ground in Finland, may facilitate multiprofessional cooperation and increase the health personnel’s knowledge of their local clients. So far, however, there is very little research available on the incidence of depression among the clients of nurses, the outcomes of the work done by nurses to diagnose and treat depression or the differences in these outcomes between the sectorised and traditional operating models.