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October 10, 2018

By: Name withheld by request

Depression and substance abuse: The danger of being strong for far too long

Editor’s note: This blog is a supplement to the continuing nurse education program Suicide among nurses: What we don’t know might hurt us.” It illustrates how our nurses colleagues too offer suffer in silence, reluctant to seek help. The author’s identity is not shared per request; unfortunately, there is still stigma associated with mental health issues. We thank the author for the courage to share this personal story.

Burnout, compassion fatigue, and lateral violence often coexistwith, or contribute to, depression in nurses. Untreated depression can lead to thoughts of self-harm and in the worst-case scenario, even suicide. This account describes my journey along the downward spiral of depression. It illustrates the barriers nurses face to get the help they need, and system issues that can exacerbate the problem.

I hope that my story helps humanize the issue of depression in nursing, so that we can begin to work as a profession to remove treatment obstacles and create preventive measures to optimize the health of our nursing workforce. When I became a nurse, I finally felt like I was a part of something bigger, better than what I ever was as an individual. I had an “elitist” mentality because I could do what many people, could not. One would think with the amount of knowledge acquired on the job and within the classroom, I would be my best patient advocate. Unfortunately, I was my own worst enemy.

Learning to hide

I learned early on in my career that as a nurse, I would never be a “regular” patient again. I have never felt comfortable revealing that I am a nurse who has depression. I want the medical team to have an unbiased view of my aliments, with no judgment.

The reason is that I have personal examples of the stigma that affects nurses when anything having to do with mental health arises. During my health screening before working in the emergency department (ED), I was asked to list my medications. This was my first position as a nurse, and since they asked, I was honest, and listed Prozac, an antidepressant that I had been on since I was 18. The nurse practitioner reviewed my chart and said, “Maybe you should think about another department. I see that you are taking Prozac. The ED can be very stressful and demanding.”

This was a defining moment in my career. I was expected to educate patients along with their family members that it was acceptable to take medications for mental health issues such as depression. Your life was not over. You are not defined by this disease. I had falsely assumed that because society was being educated, and the stigma that comes along with seeking and adhering to treatment for depression was decreasing, that I was in a safe place to disclose this as a nurse. I never felt so insecure, ashamed, and idiotic for thinking that nurses would be treated with the same grace as how we treat the public.

Keeping secrets

During my first year as a nurse, I was warned about burnout. You didn’t want to become the nurse who was angry, who did not care, or who refused difficult patient loads. You wanted to be a team player, the best you could be for your fellow nurses and for the patient. I was told, “The minute you reach burnout, you need to leave the field,” and “The selfish nurse is a worthless nurse.” I was exposed to many common risk factors for burnout, including 12-hour shifts, day or night, sometimes rotating between both; excessive documentation requirements; the churn of patient flow and turnover; working understaffed; and exposure to the raw emotion of death.

Smiles were required, “even through the telephone,” as one of my managers said. Many who were not in my field would ask me why I continued to put myself through this way of life. I would respond that I stayed for the patients and the other nurses. I was an important part of a team. If I left, who would take my place? I was strong, I could take the most difficult patient load through a difficult shift, and was always willing to pick up an extra shift.

Maybe I would have been fine if my personal life had been all rainbows and unicorns, but like most, life caught up with me. For years I hid my “dirty secret” of depression, along with the other stressors that came along with living. I would walk around work with a smile pasted on my face, even though my personal life was crashing around me. I got married and divorced, pets passed, I endured the stress of a dysfunctional family, and experienced a car accident that took me away from the unit and into a desk job. Through all of this, I never allowed anyone to see the crack in my façade. I carried a tough external composure to ensure my colleagues that I was in complete control.

To myself, I would make excuses for not dealing with the issues that I was undertaking. I didn’t have cancer, I had a career. I had a roof over my head. I wasn’t like the patients I took care of who were on their fourth conviction for driving under the influence (DUI) or addicted to drugs. I talked with friends, yes they were nurses, but I never really opened up to them about how bad my stress and depression was getting. I could still run half marathons, go drinking, and make everyone laugh. No one witnessed the real me at home when I literally could not get out of bed, or when I would drink just so I could rest my mind because it was constantly in motion. No one was aware that my undertreated mental health problems became so bad that I would take handfuls of pills with alcohol hoping not to wake up the next morning, but somehow repeatedly survived.

Fear of seeking help

Reading this one might ask why I didn’t seek help. I had insurance and access to mental health treatment. So what was the problem? I was working for the state at the time, performing surveys and investigating complaints. Everyone knew me. After the experience I had in my very first position, and what I have witnessed since, I knew that if anyone found out that I had issues with mental health I would be called unstable, and my credibility would be thrown out the window. I would be a laughing stock; the reputation I had built as a tough, efficient, hardworking, intelligent nurse would be destroyed.

Further, I knew everyone involved in my treatment. Nurses everywhere face this; either your insurance coverage is best if you receive it through your employer, making it likely you will know you providers professionally as well as personally, or you live in a small town where you know all of the providers and work with them closely. I did seek help of a therapist, who didn’t believe me or understand my concerns. I had recently gone to the ED for stomach pain and I again gave my medication list (Wellbutrin now). The doctor asked me why I was on so much, said that I didn’t need to be on that much, and attempted to decrease my dose. Mind you, he had just met me as a patient, and more importantly, had no idea that even that high dose of medication had not yet controlled my depression.

The spiral deepens

Fast forward a couple of months: Life was rearing its ugly head again.  I had accepted a leadership role in the quality department at a new facility. This was a step up for my career and a dream job for me.  After a couple of months, I noticed that the facility did not want to better themselves, but rather manipulate the system to look like they were following federal and state regulations.  When I found some major issue within the facility that could possibly affect my license, I brought it to the attention of the board.  I was asked to leave when I did not agree to keep the issue quiet. After losing my job, my boyfriend broke up with me, I lost my housing and had to move back home and start all over. After a night out with friends, attempting to deal with my stress with alcohol, I received a DUI. I had to have my parents pick me up, probably the lowest point in my life until that time. I lost a fantastic job opportunity, disappointed a lot of friends and family, and definitely disappointed myself. How could I have let this happen? I was the person who had my life all put together, at least that is what everyone thought.

That day my life turned for the worse. The DUI trapped me in a system that I could not get out of. It woke me up, but there was no way out. If I were anyone else, I might have asked for help, sought counseling, and stayed out of trouble, realizing the error of my ways. But as a nurse it’s a different story. Now I am at the mercy of the board of nursing (BON). I could lose my whole career. The disciplinary action that can be imposed by your BON varies from state to state, but examples include a reprimand, probation, suspension of a license, and revocation of a license.

It can take up to 2 years for the BON to file an action against me, and by then, my whole DUI could be closed and expunged from my record. I was advised to get an attorney who specializes in this dealing with BON cases, which I did. While I wait for the BON to act, I have been advised to do everything possible to show that I am going above and beyond to prove how much I have turned around my life. I am going to AA meetings every week, I see a therapist every 2 weeks, and I am completing my required education mandated by the department of motor vehicles all while working a full time job.  My calendar is pretty full and at first it was overwhelming, but through it all, I am finally finding myself again.  Nursing does not define me, I am defining myself.

Calling for compassion

Nurses are the epitome of compassion. But while physicians have embraced the issue of burnout, suicide and depression, even mandated wellness programs in residency programs, nurses have been slow to follow. We have evidence that there is a problem, but little effort has been made to truly assist and help nurses with mental health issues.

This is where we come full circle. Maybe if nurses could support each other and recognize that we are human, we could prevent nurses from spiraling out of control, like many of us have, but are too afraid to admit. If we practiced what we preach and decreased the negative talk about mental illness amongst our own, we could encourage more nurses to get the help they need before turning to alcohol and drugs, before suicidal ideation sets in.

Why don’t we take a page out of our book and treat the situation like we do with root cause analysis after significant clinical events. Is punishment the action plan to finding a nurse depressed and drinking herself to death? Driving intoxicated is never condoned, but couldn’t we back this up, address the root cause of the problem by eliminating stigma, proactively finding nurses who need help and encouraging them to seek treatment?

I wonder if the nurse practitioner knows the damage she caused that day by telling me I wasn’t welcome in the ED while being treated for depression. Words can help or heal; we need to choose them wisely, using the same careful respect with each other that we do with our patients.

Even now, I’m afraid of the outcome writing this might have on my career, my future, and what my colleagues might think of me. Many of them might say “I would never let it get that far, to let this take control of my career.” I was once one of those people, until I actually experienced the situation. I’m writing this because I no longer want to be part of the problem, but instead a part of the solution. Nurses deserve to have the same right as the rest of the public—for their records to remain private and for their diagnosis not to define what they are capable of contributing to the profession.

Let’s all take action to decrease the stigma of mental illness in the profession, and look for those with burnout, and compassion fatigue because they might be signals of co-existing depression. In the unfortunate event of a DUI or suicide attempt, let’s turn the system around to see this as a cry for help; a lost soul in need. Instead of labeling these people as an organizational risk and moving them out, let’s restructure the process so that nurses are supported through the necessary pause in their career to receive the help they need and then welcome them back. Finally, let’s all embrace returning nurses who win the battle against depression, while retaining their dignity, as we would with soldiers after war.

Final thoughts

I am taking each day as it comes. The anger and shame is still there, and I do not know if it will ever go away.  Will I ever be able to share my experience freely without the fear of being judged or worse, having my career taken away from me?  I don’t know. As of now, I will still stay in the shadows.

After many months of rejections, I was hired by a manager who knew about my situation and had the grace to take a chance on me. Unfortunately, if the BON decides to place restrictions on my license, the facility will have to let me go because they are not able to keep RNs who have restrictions on their licenses.

I feel that I am getting a handle on how to cope with daily stressors, depression, and that I am accepting the fact that I am human, and that is ok. I am learning how to say no and how to put myself first, and it is creating a better atmosphere for my professional and home life. I still haven’t forgiven myself, I don’t know if I ever will.  Maybe one day.

 

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