Assessment to the presence of depressive symptoms among users nightshift at emergency room


Igor Pereira dos SantosI; Antonia Regina Ferreira FuregatoII

I RN, Campinas City Administration. Master's degree in Psychiatric Nursing by University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, São Paulo, Brazil. E-mail: rogerspy@yahoo.com

II Full Professor, Collaborator of the Department of Psychiatric Nursing and Human Sciences, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, São Paulo, Brazil. E-mail: furegato@eerp.usp.br




Depression is a disease with personal and social losses. We aimed to know the clinical and contextual factors related to the presence of depression in users of night-shift services, in a emergence unit. Descriptive, exploratory, cross-sectional study conducted in 2008, Campinas/SP, with 62 adults who searched for care. A questionnaire with personal, psychosocial and clinical information and the Beck's Depression Inventory (BID) were applied. Statistics analyses were carried out. The results showed 62 subjects were between 18 and 56 years old, 75.8% women, 71,8% white and 53,2% single, all subjects worked and none of them were illiterate, 21% had university studies; they had digestive complaints and headache (32.2%) and reported problems at work (12.9%) and alcohol and drug abuse in the family (17.7%). According to BID, 21% of the subjects were depressed. The test showed correlations for smoking (p=0.021), insomnia (p=0.005), economic problems (p<0.000). We concluded that compared to unsuspected samples, symptoms were high, but in accordance to disease-related depression.

Keywords: Depression; emergencies; night shift; nursing.




Emergency, first aid, and ambulatory care units receive a large number of patients who show acute signs of various afflictions. Hospital emergency rooms rapidly provide medical consultations and general care, of any specialty, for immediate action to avoid death or severe complications.1-4

The frequent correlation between clinical diseases and depressive symptoms in patients that seek basic health services and hospital emergency room services are probably the results of emotional, physical and psychological factors related to certain diseases, which require constant attention, early diagnosis and proper treatment from the team of healthcare professionals.2,5-8

Depression can appear masked by chronic headache, dyspepsia, lack of appetite, constipation, insomnia, weakness, self-aggression and the improper use of medicines and other substances. Unfortunately, the possibility that such a situation is representative of depression is not always investigated by health care professionals. Thus, many depressed patients who seek care in the basic health care network or in secondary clinical care remain undiagnosed and without proper treatment, resulting in an excessive amount of suffering, increased morbidity and mortality, and a continuous risk of suicide. 1,2,5,6,8,9

In spite of the creation of extra-hospital services such as day hospitals, treatment residences, outpatient care units and psychosocial care centers (CAPS), the process of deinstitutionalization, with reduced numbers of beds and the closing of many psychiatric hospitals and asylums, has increased the number of unstable patients in the community, and re-admittances to hospital and specialized emergency care.10-12

For this and other reasons, emergency services health care professionals attend to a much higher demand than expected. Additionally, to provide first aid care in emergencies that involve the risk of or attempted suicide, delirium, aggression toward oneself and others, disturbance and depression requires competence by teams of health care professionals in regard to the safety of the patient who is suffering, and quality of care provided.2-4,6,13

Nursing care has an important role for the health and well being of patients in all services of the Brazilian public Unified Health System (SUS) network. In emergency care services, the nurse races to receive the patient with his or her complaint, provide care and give the necessary referrals. Communication and empathy stand out among the skills necessary for a nurse to effectively provide health care.14-18.

This study sought to identify depression among night shift patients in an emergency room of a general hospital, and relate this to clinical and contextual indicators.



Everyone goes through difficult times in which they feel sad, alone and unhappy. Most of the time, the person is experiencing a normal and understandable feeling, because suffering is a condition of human existence, and does not always represent a pathological condition.1,3,5,19

Depression is one of the mental disorders that presents complex diagnosis, with a group of persistent physiological, psychological and behavioral symptoms, the primary ones being a depressed mood and loss of interest. Depression primarily afflicts young adults between the ages of 20 to 30, and is frequently associated with other illnesses. It causes intense suffering, and because it involves so much bias, is frequently denied by the individual who suffers from it.1,3-5,19

It is a debilitating and incapacitating illness that decisively and intensely interferes in the personal, professional, social and economic life of afflicted individuals. The most marked characteristic of the illness is sadness and related difficulty to resolve day-to-day conflicts, reduction of overall activity, ideas of guilt or ruin, and feelings of incapacity and inferiority.1,3,5,7,19

An epidemic of the century, it is considered by the Pan-American Health Organization and World Health Organization to be a public health problem. By 2020, it is estimated that in developed countries, it will be the biggest cause of years lived with incapacity. Depression afflicts 15 to 20 percent of the population at some point in life, with high rates of suicide.3,5

Many people live in a depressed state for a long time, without seeking specialized help because they do not know that their condition is a manifestation of an illness that should be diagnosed and properly treated.5,19



This was an exploratory, descriptive study, with application in clinical practice in a general hospital, with a focus on mental health.

The study was performed in the First Aid and Emergency Care Unit of the Irmãos Penteado Hospital in Campinas, São Paulo - a private institution treating private patients and patients with health insurance. The study population was night shift patients in the units cited above.

The First Aid and Emergency Care Unit of the Hospital Irmãos Penteado treats about 2500 patients per month. During the study period, the night shift for this unit treated 353 patients. The sample was composed of 62 (17.6%) adult participants with physical and clinical conditions to respond to the interview. Two instruments were used for data collection, these being a targeted questionnaire and the Beck Depression Inventory (BDI).

The questionnaire contained questions regarding subjects' personal identification information (age, sex, ethnicity, level of education, place of birth, marital status, living arrangement, employment and religion), clinical information (vital signs, reason for seeking medical treatment, medications/drugs being used, previous consultations, chronic illnesses, previous diagnosis of depression, sleep, physical activity, diet, habits, vices and previous use of psychological or psychiatric care), and psychosocial context data (significant events, relationship problems, divorce, family and economic problems, retirement, housing satisfaction, change of residence, use of community resources and leisure, as well as volunteer work).

The Beck Depression Inventory (BDI), created more than 50 years ago at the University of Pennsylvania, in Philadelphia, Pennsylvania, USA,20 was translated and validated for Brazil, and has been amply used in tracking and clinical research, varying only in regard to the cutoff points.21

The project was approved by the Research Ethics Committee (REC) of the School of Nursing of Ribeirão Preto at the Universidade de São Paulo (protocol 0814/2007), and by the REC of the Hospital Irmãos Penteado (protocol 026/07).

Data collection took place during the night shifts, adhering to the work schedule of the researcher/nurse (twelve hours of work per 36 hours of rest). All of the patients sought treatment at the end of 2007 and beginning of 2008; they agreed to participate in the research during their admittance performed by the nurse, and while awaiting medical consultation, and were ordered by arrival, age, degree of lucidity, comprehension and reading capacity. Situations of clinical risk were avoided by only interviewing the next patient after the previous interview had been completed with care and time. Anonymity and safety were guaranteed. All of the participants were oriented regarding the study procedures, and signed the Free and Informed Consent Form. The questionnaire was applied in the form of an interview, while the BDI was read and responded to by the subject him/herself.

The identification, contextualization and clinical information of the study subjects were submitted to descriptive analysis. Because the population studied was non-suspect, and the objective was not to diagnose but to seek signs and symptoms indicative of depression, the cutoff points used for classification of the scores were: ≤15 being considered no depression, 16 to 20 light depression, 21 to 29 moderate depression, and ≥30 major depression.21

The results were statistically analyzed through bivariate and multivariate analysis, using Fisher's exact test22 for statistical significance, correlating the presence of symptoms of depression with the following variables: habits (smoking, drinking), insomnia, obesity, hypertension, sex, physical activity, previous depression and financial problems.



The socio-demographic data showed that participants' ages varied from 18 to 56 years, and 30 (48.4%) subjects were aged between 21 and 30. Fifteen study participants were (24.2%) men, and 47 (75.8%) were women. The majority of the sample (49 participants, or 71.8%) identified themselves as racially white. Thirty-three (53.2%) participants were single, and 35 (56.5%) lived without a partner. Forty-six (74.2%) participants had completed secondary school, and 13 (21%) had complete or incomplete higher education. Not one respondent declared him/herself to be unemployed or without work, and one retired participant remained working. The occupations of the 62 study subjects were distributed in the following areas: commerce – 11 (17.7%), health – 7 (11.3%), education – 1 (1.6%), administration – 19 (30.6%), industry – 4 (6.5%), general cleaning services – 4 (6.5%) and others – 16 (25.8%). Work-related problems such as stress with colleagues and superiors, were reported by eight (12.9%) subjects, as shown in Table 1.


In regard to clinical situation, 20 (32.2%) cited headaches and 26 (42%) cited insomnia. At the time of consultation, 14 (23.2%) of the subjects had light to moderate hypertension.

When the subjects were questioned as to whether or not they had been previously diagnosed with depression at some point in their lives, eight (12.9%) responded affirmatively, seven (11.4%) of which were women. When questioned whether they had already undergone psychiatric treatment, six (9.7%) responded affirmatively.

Insomnia was reported by 26 (41.9%) of the participants, which was characterized as initial by 16 (25.8%), intermittent by seven (11.3%) and final by three (4.8%).

More than half of the subjects (35; 56.5%) denied having family problems, though five (8.1%) cited problems with their partner. It is interesting to note that eleven (17.7%) subjects cited problems with alcohol and other drugs within their family, and 28 (45.3%) of subjects said that they use alcohol, albeit socially.

Financial problems were cited by nine (14.5%) study subjects, even though the sample was of a population that has health insurance, offered as an employment benefit or paid for individually.

The results of the study about the presence or absence of depression showed that 13 (21%) subjects presented signs or symptoms of depression, with five (8.1%) exhibiting moderate depression and eight (12.9%) exhibiting light depression. The majority of the study subjects did not present signs or symptoms of depression. Not one study subject showed signs or symptoms of major depression, as shown in Table 2.


The results from questions 4, 8, 11, 16, 17 and 20 of the BDI were notable, because they showed significant changes for the majority, or close to the majority, on the choices of leisure, self-criticism, sleep, exhaustion and concern about health, respectively.

All of the variables of interest were crossed with the presence or absence of depression, calculating the p-value from Fisher's exact test (bivariate analysis).

The Fisher exact test showed statistical significant for the variables: tobacco smoking habit (p=0.021), insomnia (p=0.005) and financial problems (p<0.000), as can be seen in Table 3.




The emergency care service of the hospital where this research was carried out treats patients with individual or group health insurance, 24 hours per day. Therefore, it is worth noting that the sample of those treated during the night shifts, during the period of this study, was predominately composed of white women between the ages of 18 and 30, with a good level of education. The majority of the participants are employed, have good living conditions, live alone and practice physical exercise. However, they also exhibit headaches and insomnia, some had been previously diagnosed with depression, and use alcohol and/or tobacco. They also reported problems with alcohol and other drug abuse in their families, and stress and relationships difficulties at work .

The study sample represents a portion of the population that is asking for attention, outside of the medical consultations and other medical procedures, during the day, in the network for basic health care.

This research worked with patients who were not diagnosed with depression; that is, no one sought care complaining of depression. While they sought the service for other reasons, more than 20 percent of the sample showed signs of light or moderate depression, which nonetheless is a significant rate of depression.

However, a prevalence of 12 percent of dysphoria and 8 percent moderate depression among the subjects does not differ from the rates found among the general population.3-5,7,10,19 Because the sample already showed some clinical situation, and the subjects were seeking care in a health care service, it is possible to say that this sample was not entirely insuspect.

The results of this study did not find a direct relationship between levels of depression and illnesses such as obesity, diabetes or heart attack, possibly because the study participants were relatively young. Depressed patients have a significantly higher risk of developing ischemic heart disease and/or hypertension, and vice versa.6,23,24

In regard to gender, the results of this research confirm the literature, with women twice as likely to suffer from depression than men. Similarly, the age of those respondents with depression corresponds to young individuals. The literature shows that depression is more frequent among young adult women, and people between the ages of 25 and 44 are more susceptible, with certain predisposing environmental factors such as urbanization and changes in family structure.1,5,6,8,25.

Despite the high frequency of headaches, it was expected to find a greater prevalence of depression in the clinical complaints of this sample, as suggested in the literature. However, the statistically significant association between depression and tobacco smoking, insomnia, and financial and work-related problems was clear.9,13,26

Smoking appears as a negative factor for depressed individuals, which positively corroborates the data from the scientific literature, which acknowledges a strong association between tobacco use and depression disorders. Quitting smoking has been considered a risk factor for the maintenance of the clinical picture, or the development of new depression illnesses and panic crises.27-29

In the group studied, smoking was a daily practice while alcohol was reported as being used socially, especially on the weekends.

Insomnia was also a factor that showed negative significance on the Fisher test. Insomnia and psychiatric disorders are intimately associated, with greater prevalence of the difficulty to fall and stay asleep, which was reported as initial insomnia. It is a marked characteristic of depressive disorder, and can occur in the first stages of depression, as well as precede or be a residual symptom of depression, which makes greater attention to insomnia necessary, keeping in mind the ease of verbalizing sleep difficulties by the patient.8-9, 30

Of the family-related questions, relationship problems with partners and many complaints of problems related to the use of alcohol and drugs by family members were cited, which warrants future studies.

Financial problems were significant among the individuals with depression, which calls attention to the fact since they were all employed. However, in the open-ended questions of this study there were various complaints of work-related stress, misunderstandings with work colleagues, and demands from superiors, among others. In light of these facts, the importance of perceiving the needs of workers and to therapeutically intervene is perceived, before depression becomes a motive for severe and even irreparable losses.

If psychiatric unbalances are going to appear with greater frequency in the emergency rooms and first aid services of general hospitals, it is the health care team's responsibility to treat these clinical cases, or those associated with depression or other psychiatric illnesses, and present better conditions for improvement, considering the high degree of suffering that accompanies them.3,6,8,10

However, it is already known among specialists in this area that only one-third of depressed patients are adequately treated, with the others being underdiagnosed or inadequately treated, compromising their adherence to treatment.3,6, 8,10

The nurse operates doubly among hospital services, including emergencies: as much in the support of medical care as in the autonomous core. Emergency services, centered on the biomedical model, attend to the needs of the patient and count on resolute actions of nursing care, which should be exercised with the best possible quality in receiving the patient, according to the need presented.15-18



The characterization of the night-shift emergency room patients took into account identification, clinical and social context information of the study subjects.

A significant presence of depression among respondents was observed that was higher than that found in the general population, yet compatible with the presence of clinical problems, and in accordance with the context.

Statistical analysis highlighted the negative relationship between smoking, insomnia and financial problems, as well as the relationship of clinical and contextual data, with the depressive symptoms identified in the study.

It is hoped that nurses will be attentive to these questions, aiming for qualified observation and improved quality of care provided in emergency room services.

Among the study's limitations, the small sample size (institutional) is highlighted, as it impedes generalization of the findings.



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Direitos autorais 2013 Igor Pereira dos Santos, Antonia Regina Ferreira Furegato

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