ASPECTOS ÉTICOS

PNS foi aprovada pela Comissão Nacional de Ética em Pesquisa - CONEP, do Conselho Nacional de Saúde - CNS, em junho de 2013 (BRASIL, 2014). Sendo importante destacar, que os dados utilizados no presente estudo, foram não identificados, não havendo possibilidade de identificar o sujeito, garantindo a privacidade, confidencialidade e anonimato entre os dados analisados.

Os resultados e discussões deste trabalho são apresentados nesta seção por meio de dois artigos científicos produzidos com os dados coletados. O artigo 01, intitulado ”Prevalence and factors associated to depression in Brazilian women at reproductive age”, foi submetido para o Journal of Public Health, que possui Qualis A2 da CAPES para area 21(Educação Física, Fisioterapia e Terapia Ocupacional) e fator de impacto de 2.666. O artigo 02 tem como título ”Physical therapy on depression management in women in the Brazilian context”, foi submetido ao periódico Physiotherapy, qualis A2 para a área 21 e fator de impacto 1.814.

4.1 ARTIGO 1

Prevalence and factors associated to depression in Brazilian women at reproductive age

Adriana Gomes Magalhães, PhD¹, Damião Ernane de Souza, PhD ², Diego de Sousa Dantas, PhD ¹, Fernanda Diniz de Sá, PhD ¹, Palloma Rodrigues de Andrade, PhD ³, Elizabel de Souza Ramalho Viana, PhD 4

¹ Universidade Federal do Rio Grande do Norte, Faculdade de Ciências da Saúde do Trairi Santa Cruz, Rio Grande do Norte, BR Postal Code 59200-000

² Instituto Brasileiro de Geografia e Estatística. Natal - RN, BR Postal Code 59000-000 ³ Universidade Federal da Paraíba. Joao Pessoa, PB, BR Postal Code 58000-000 4

Universidade Federal do Rio Grande do Norte, Departamento de Fisioterapia Natal, RN, BR Postal Code 59000-000

corresponding author: Adriana Gomes Magalhães

Abstract

Background: the depression is a global public health problem that affect the persons and the context in which he lives. However, in Brazil, epidemiological population-based studies to investigate the factors associated with this occurrence are scarce, especially in women of reproductive age.

Methods: 22,621 women aged 18-49 years were analyzed from the Brazilian National Health Survey, 2013. The outcome was depression diagnosis, independent variables were sociodemographic items, lifestyle, reproductive history and chronic diseases. Descriptive and bivariate data analysis were conducted.

Results: there was a prevalence of 8.26% of depression diagnosis, socio- demographic factors and lifestyle habits were associated to depression diagnosis. Women who have had sexual intercourse, who used contraception and were pregnant were less likely to have depression. In contrast, women with self-reported poor health, victims of violence from a known person or unknown person, with menarche before twelve years, with at least one delivery, submitted to cesarean section, with low birth weight child or preterm were more likely to have depression. Chronic conditions increased chances for depressive outcome.

Conclusions: This study showed considerable prevalence of depression among the women studied, as well as its association to sociodemographic factors, gynecological and reproductive history and health conditions.

Keywords: epidemiology, Gender, Mental Health

Introduction

Depression is a public health problem and affects patients, families and caregivers1,2,3, and it is among the ten leading causes of disability in the world4. It is estimated that by 2020, this disorder will be in second place in this ranking5. However, depression is underdiagnosed, making it difficult to trace their symptoms2,6,7,8,9. It is an affective disorder, characterized by depressed mood, loss of interest or pleasure, decreased energy and decreased activities of daily living, followed by feelings of sadness and low self-esteem1,10,11.

Women are twice as affected by depression than men2,12,13,14,15. This difference in prevalence between genders appears in adolescence, suggesting

a link between the occurrence and increased levels of sex hormones16,17,18. Issues such as low status and social support, high workload and violence predispose women to greater vulnerability, contributing to greater illness by this condition17,18,19,20,21.

In Brazil, women are most of the population and most users of public health services22. The National Health Policy of Integral Attention for the Brazilian Woman proposes that mental health should be addressed on the assumption that women suffer doubly with the consequences of mental disorders, given the social, cultural and economic conditions in which they live. Currently, women have accumulated more social roles, which increase their emotional overload22.

Population studies show that women have a worse self-reported health, lower education levels and lower wages compared to men23,24. However, few studies have explored the determinants and conditions of depression in women during the fertile or reproductive years (from 15 to 49 years old), a period marked by physiological events associated to sex hormones and more prone to disorders, such as depression.

This study aims to analyze the prevalence of depression and its association with sociodemographic factors, gynecological and reproductive history and health conditions in Brazilian women at reproductive age.

Methodology

This study was based on data from the National Health Survey - PNS. This is a cross-sectional, population-based, held in Brazil in 2013 by the Brazilian Institute of Geography and Statistics (IBGE), on demand of the Ministry of Health, with technical support of Oswaldo Cruz Foundation (FIOCRUZ) and University of São Paulo (USP). The National Health Survey was approved by the National Research Ethics Commission (CONEP), the National Health Council (CNS), in June 2013.

Interviews were conducted across the country, covering 26 states and federal district. Interviews were conducted in 60,202 households, totaling 205,546 participants, from both genders, aged 18 years or older. For this analysis, it was only included data from women aged 18 to 49 years, totaling 22,621 records of women at reproductive age.

The outcome variable, depression, was assessed by self-reported diagnosis of depression, conducted by experienced personnel, according to PNS25. Independent variables included sociodemographic items, lifestyle, reproductive history and chronic diseases, categorized as follows: a) chronological age: 18-33 years and 34-49 years; b) education: complete elementary school and complete high school or a more advanced level; c) race/color: white for individuals who declared themselves as white and others for individuals who declared themselves black, brown and others; d) marital status by living or not with their spouse/partner.

It was evaluated whether the woman had labor activity, if she were a smoker, consumed alcohol and if she practiced physical activity in the past three months. It was also investigated if there was violence record against the women by a known or unknown person.

Self-perceived health status was grouped in good health, for those who have chosen the options very good, good nor bad nor good (scores 1, 2 and 3 in the displayed scale). Also, it was determined poor health for those who rated their health as poor or very poor (scores 4 and 5 in the displayed scale).

Gynecological variables and reproductive history were also categorized following criteria of the answers to their questions.

Finally, data on the occurrence of chronic morbidities such as hypertension, diabetes, asthma or chronic bronchitis, rheumatic problems and spine chronic problems were included.

Descriptive analysis of the variables of interest was carried out, and the absolute and relative frequencies were obtained. Then bivariate analysis was made to estimate the association magnitude between exposure variables and depression diagnosis, expressed as odds ratio (OR) and confidence intervals of 95% (CI95%) using Mantel-Haenszel method for statistical inference. Analyses were performed by STATA®, version 9.

Results

Data were analyzed regarding 22,621 women at reproductive age. The women rated their general health as good (95.7%) and had a depression prevalence of 8.26% (Table 1).

Table 1. Sociodemographic, gynecologic and reproductive characteristics and general health conditions of Brazilian women at reproductive age (n = 22,621, Brazil, 2013) Variables Total n = 22,621 n % Sociodemographic data Age group 18 to 33 years 11,554 51.08 34 to 49 years 11,067 48.92 Race White 8,443 37.32

Black, Brown and others 14,178 62.68

Live with partner or spouse

No 8,830 39.03

Yes 13,791 60.97

Education

Up to Elementary school 10,123 44.75

High school or more 12,498 55.25

Working No 11,103 49.08 Yes 11,518 50.92 Lifestyle Smoker No 20,392 90.15

Yes 2,229 9.85 Alcohol comsuption

No 15,482 68.44

Yes 7,139 31.56

Physical Activity 3 months

No 16,738 73.99

Yes 5,883 26.01

Self-reported health

Good 21,659 95.75

Poor 962 4.25

Violence by a unknown person

No 21,809 96.41

Yes 812 3.59

Violence by a known person

No 21,705 95.95

Yes 916 4.05

Gynecological and reproductive history Menarche

≤12 years 10,076 44.54

> 12 years 12,545 55.46

Sexual intercourse last 12 months

No 4,812 21.27

Yes 17,809 78.73

Use of contraceptive method

No 12,077 53.39 Yes 10,544 46.61 Pregnant No 21,821 96.46 Yes 800 3.54 Parity No parturition 6,446 28.50 1 parturition or more 16,175 71.50 Type of parturition* Vaginal 7,597 46.97 Caesarian 8,578 53.03 Underweight children* No 13,846 85.60 Yes 2,329 14.40 Preterm child* No 13,691 81.91 Yes 2,484 18.09 Chronic conditions Arterial hypertension 2,452 10.84 Diabetes 532 2.35

Asthma or Chronic Bronchitis 1,169 5.17

Depression 1,869 8.26

Rheumatic diseases 845 3.74

Spinal chronic problem 3,355 14.83

Association between independent variables and outcome depression was observed and data showed in table 2

Table 2. Association among analyzed variables and depression in Brazilian women at reproductive age (Brazil, 2013).

Variables Depression Odds CI 95% Yes n (%) No n (%) Age group 18 a 33 anos 642 (5.56) 10,912 (94.44) 1.0 34 a 49 1,227 (11.09) 9,840 (88.91) 2.12 1.92 - 2.34 Race White 858 (10.16) 7,585 (89.84) 1.0

Black, Brown and others 1,011 (7.13) 13,167 (92.87) 0.68 0.62 - 0.75 Live with partner or spouse

No 781 (8.84) 8,049 (91.16) 1.0

Yes 1,088 (7.89) 12,703(92.11) 0.88 0.80 - 0.97

Education

Up to Elementary school 918 (9.07) 9,205 (90.93) 1.0

High school or more 951(7.61) 11,547 (92.39) 0.83 0.75- 0.91 Working Yes 999 (8.67) 10,519 (91.33) 1,0 No 870 (7.84) 10,233 (92.16) 0.89 0.81- 0.98 Smoker No 1,557 (7.64) 18,835 (92.36) 1.0 Yes 312 (14.00) 1,917 (86.00) 1.97 1.73 - 2.24 Alcohol comsuption No 1,257 (8.12) 14,225 (91.88) 1.0 Yes 612 (8.57) 6,527 (91.43) 1.06 0.95 - 1.17 Physical Activity* No 1,341 (8.01) 15,397 (91.99) 1.0 Yes 528 (8.98) 5,355 (91.02) 1.13 1.09 - 1.26 Self-reported health Good 1,623 (7.49) 20,036 (92.51) 1.0

Poor 246 (25.57) 716 (74.43) 4.24 3.64 - 4.94 Violence by a unknown person No 1,755 (8.05) 20,054 (91.95) 1.0 Yes 114 (14.04) 698 (85.96) 1.86 1.52 - 2.28 Violence by a known person No 1,694 (7.80) 20,011 (92.20) 1.0 Yes 175 (19.10) 741(80.90) 2.79 2.35 - 3.31 Menarche ≤12 years 994 (7.92) 11,551 (92.08) 1.0 > 12 years 875 (8.68) 9,201 (91.32) 1.10 1.01 - 1.21 Sexual intercourse** No 473 (9.83) 4,812 (90.17) 1.0 Yes 1,396 (7.84) 16,413 (92.16) 0.78 0.69 -0.87 Contraceptive method No 1,099 (9.10) 10,978 (90.90) 1.0 Yes 770 (7.30) 9,774 (92.70) 0.78 0.71- 0.86 Pregnant No 1,838 (8.42) 19,983 (91.58) 1.0 Yes 31(3.88) 769 (96.13) 0.43 0.30 - 0.63 Parity No parturition 365 (5.66) 6,081 (94.34) 1.0 1 parturition or more 1,504 (9.30) 14,671 (90.70) 1.70 1.52 - 1.92 Type of parturition Vaginal 610 (8.03) 6,987 (91.97) 1.0 Caesarian 894 (10.42) 7,684 (89.58) 1.33 1.19 - 1.48 Underweight children No 1,231 (8.89) 12,615 (91.11) 1.0 Yes 273 (11.72) 2,056 (88.28) 1.36 1.18 - 1.56 Preterm child No 1,165 (8.51) 12,526 (91.49) 1.0 Yes 339 (13.65) 2,145 (86.35) 1.69 1.49 - 1.93 Hypertension No 1,441 (7.14) 18,728 (92.86) 1.0 Yes 428 (17.46) 2,024 (82.54) 2.75 2.44 - 3.09 Diabetes No 1,778 (8.05) 20,311 (91.95) 1.0 Yes 91(17.11) 441 (82.89) 2.36 1.87 - 2.97 Asthma or Chronic

Brown, black or other women (OR=0.68; CI95% 0.62-0.75), without a partner (OR=0.88; CI95% 0.80-0.97), with high school or more (OR=0.83, CI95% 0.75 -0.91), who do not work (OR=0.89; CI95% 0.81-0.98), who had sexual intercourse in the past year (OR=0.78; CI95% 0.69-0.87), who use contraceptive methods (OR=0.78, CI95% 0.71-0.86) or were pregnant (OR=0.43; CI95% 0.30-0.63), they were less likely to have depression. In contrast, women aged 34-49 years were 112% more likely to have depression (OR=2.12; CI95% 1.92-2.34). Similarly, smoking (OR=1.97; CI95% 1.73-2.24) and to practice physical activity in the last three months (OR=1.13; CI95% 1.09- 1.26) increased the odds for development of depression in 97% and 13% of the sample, respectively.

Women with self-reported poor health (OR=4.24; CI95% 3.64-4.94), violence victims from a known person (OR=2.79; CI95% 2.35-3.31) or unknown person (OR=1.86; CI95% 1.52-2.28), were respectively, in approximate values, 4, 3 and 2 times more likely to mention depression.

It was also observed that women with menarche before twelve years (OR=1.10; CI95% 1.01-1.21), with at least one delivery (OR=1.70; CI95% 1.52- 1.92), submitted to cesarean section (OR=1.33; CI95% 1.19-1.48) with underweight child (OR=1.36; CI95% 1.18-1.56) or preterm (OR=1.69; CI95% 1.49-1.93) were more likely to have depression.

All chronic conditions analyzed: hypertension, diabetes, asthma or chronic bronchitis, rheumatic and spinal chronic problems increased the chances for depressive outcome in the sample.

Discussion Bronchitis No 1,666 (7.77) 19,786 (92.23) 1.0 Yes 203 (17.37) 966 (82.63) 2.49 2.12 - 2.93 Rheumatic diseases No 1,659 (7.62) 20,117 (92.38) 1.0 Yes 210 (24.85) 635 (75.15) 4.01 3.40 - 4.72

Spinal chronic problem

No 1,271 (6.60) 17,995 (93.40) 1.0

This study analyzed depression prevalence and associated factors in Brazilian women at reproductive age. There was depression prevalence of 8.26% in these women. This value is lower than that found in other developing countries, such as Chile and South Africa, where depression prevalence was 15.3% and 10.3% respectively26,14. This may be explained by socioeconomic differences and access to health services in Brazil and the countries mentioned.

There is evidence that estrogen fluctuation, its sudden withdrawal or its sustained deficit, correlate with significant disturbance of mood27. Puberty, menstrual cycle, pregnancy, and menopause can initiate, exacerbate and cause recurrence of affective disorders, such as depression28.

There is no consensus in the literature regarding the association between age and age group in which depressive episodes appear. Most studies point to a higher occurrence of this outcome among young adults5,15,29,30. In this study, it was observed that women between 33 and 49 years were more likely to have depression, confirming the results of Stordal et al31, that found an association of increasing age and increased depression prevalence. A previous study found that reporting of depressive symptoms in women, during periods of great hormonal variability, such as premenstrual periods and puerperium, is associated with greater vulnerability to depression in perimenopause32.

Race also seems to influence the risk for illness by depression, hypothesis confirmed in this study. Self-reported white women were 38% more likely to have depression than those of other races. Previous studies33,34,35 found that white women, in similar levels of socioeconomic disadvantage, are more likely to have depression than African American and Mexican women, because they have higher prevalence of dysthymic disorders. The authors suggest that race may interfere with seeking for health services and, thus, in depression diagnosis33,34.

Education seems to be a protective factor for the risk of developing depression. In this study, less educated women were more likely to have depression, confirming previously found evidence36. In a comparative analysis between Chilean and British women, there was higher risk of depression among

Chilean with low education levels14. Women with higher levels of education may have creative work and better sense of control of their lives, positively contributing to decrease in cases37. Studies support the idea that education acts as a protective factor for depression, by means of underlying mechanisms, mainly by developing cognitive capacity38 and it seems to accumulate throughout life39.

Epidemiological studies show that single or unmarried women have high risk of having depression 26,36,40,41,42. This study showed decrease in depression in women who live with a spouse or partner. This fact agrees with the evidence that marriage is positively associated to psychological well-being, both for men and women,40,41,43.

In this study, women who do not work have decreased chances of depression diagnosis. A previous study suggested that job stress may precipitate depression in previously healthy workers44. However, working influences in a complex way the woman’s life, depending on factors such as job, working hours, salary, among others. Therefore, it is not possible to establish a direct relationship between working and depression.

Lifestyle habits, such as smoking, seem to influence the appearance of depression, as evidenced in this study. Previous findings confirm that smoking might be strongly associated with depression, particularly in women45, which may present more intense levels of smoking, when there is history of depression35.

Although some studies show benefits of physical activity in reducing the risk of depression46,47 and in its treatment48, this study found an inverse association. Women who reported practice of physical activity in the past three months were more likely to have depression. This finding may be due to unspecific evaluated variable, which ignores important parameters such as type, intensity, duration and purpose of this physical activity49,50.

In this study, menarche before twelve years represented a 10% higher risk of depression diagnosis, contrary to previous study, which observed that increasing age of menarche increases the probability of having depression51.

Literature data suggest that early maturation of the reproductive axis in girls is associated to increased risk of depressive symptoms in adolescence52. However, it is not clearly established in the literature, the relationship of this variable with the outcome.

In addition, it was observed that women using contraceptives, had a lower risk of having depression. There were no data in the literature to contribute to this discussion. It should be emphasized that the analysis of this association in this study was restricted by not addressing what contraception method was used by women. Regarding sexual life, in this study it was found that women who had sexual intercourse in the last 12 months presented lower risk of developing depression. These results confirm previous study findings reporting that sexual activity has strong association with decrease of depression conditions53,54,55.

Sexual activity and pregnancy are very important protective factors for the diagnosis of depression. A previous study, that observed decrease in cases of depression during pregnancy and postpartum, showed similar results56. In contrast, concerning prevalence of gestational depression, it is highlighted that this finding in the first trimester is similar to that found in women population in general, and in other trimesters of pregnancy, it may be about the double57. Understanding these findings is important because depression and/or depressive symptoms untreated during pregnancy have been linked to increased risk of suicide, miscarriage, premature birth, fetal growth restriction and postnatal development58,59. Schappin et al. suggest that parents of preterm born children suffer more stress than parents of children born at term, and that mothers suffer more stress than fathers. This suffering can be higher when, in addition to prematurity, the newborn has low weight for gestational age60.

Mothers of low birth weight infants have continuous risk of depression during baby's first year of life61. Prenatal depression was associated with child low weight and gestational age. These findings are confirmed in this study, where women who had premature or low birth weight children were more likely to have depression.

In this study, women who had caesarean section, were more likely to be diagnosed with depression. These results confirm study that found an association of cesarean section with postpartum depression and anxiety62. Regarding parity, women who had a child or more, were 70% more likely to have depression than nulliparous women. These data confirm the results of Patel et al, which showed an association between parity and mental disorders42. Multiparous women were more concerned over lack of social support63, which can be a trigger or enhancer element of affective and mood problems related to depression.

Depression is often accompanied by chronic comorbidities7,9, which increase the negative effects on health, contributing to poor prognosis and poor quality of life64,65,66. Results from World Health Surveys7 showed that, on average, 9.3% to 23.0% of the assessed individuals have reported one or more chronic physical disease, in association with depression.

In this study, it was observed that diabetic women were more likely to have depression, confirming previous studies67,68,69. People with type II diabetes were almost twice as likely to have depression, whereas people with type I diabetes were up to three times more likely to have depression68. Additionally, authors report that these are chronic conditions that impact negatively on the individual's quality of life and compromise functionality9.

Systemic arterial hypertension (SAH) was also associated to depression in this study, contradicting study results conducted in South Africa, which evaluated the association between high blood pressure, depression and anxiety, finding only association between anxiety and hypertension70. However, other studies reported that there is considerable evidence suggesting that higher responsiveness of the sympathetic nervous system and genetic influences are the mechanisms underlying the relationship between depression and hypertension71,72.

This study also reported an association between asthma, chronic bronchitis and depression, confirming findings of previous studies, which show worst results in asthmatics73,74. Also, depression constitutes one of the factors

that may explain 50% of dyspnea in asthmatics patients75, whereas emotional stress may affect the immune system and inflammatory response76,77. It is observed that asthma can precede and predispose to anxiety and depression, and vice versa73.

Depression prevalence in people with rheumatic diseases is about twice that of the general population78. In this study, however, it was demonstrated that women with rheumatic disease, had four times higher the risk of having depression. This finding confirms results of other studies that found high prevalence of depression in patients with chronic low back pain, justifying their findings by limitation in social activities, emotional problems and decreased quality of life imposed by low back pain79, 80.

Reporting of a negative self-perception of health, increased by four fold the odds for depression in this study. In this perspective, an epidemiological study of self-reported health in the general population, demonstrated association between self-reported poor health (SRH-P) with factors related to mental health in women81. Similarly, another study found that self-report of