INTRODUCTION

The gestational period is one of the woman's life phases that exposes her to many physical and psychic changes and is associated with a greater fragility of her mental health¹. At that moment, there are changes in her body and her well-being, changing her psyche and her social-family role. It is also possible to observe the increase of characteristic symptoms of emotional distress, or even the appearance of psychiatric disorder².

Therefore, science shows that women are more likely to develop mental disorders than men, especially mood disorder, anxiety, somatoform and psychiatric comorbidities. Among the mental disorders, it was observed that Major Depressive Disorder (21.6%) and Generalized Anxiety Disorder occur more frequently (19.8%)³.

Family and societal support are crucial in all phases of life, and it is important for the stressful moments that happen daily, especially in those times when there are some psychosocial and physiological changes, as in the case of gestation. During this period, there is the most frequent stage of the common mental disorders of the woman, especially in the first and third trimesters of gestation and in the first 30 days of the postpartum period⁴.

Common Mental Disorder (CMD) can be defined as a disorder that can cause psychological distress, functional impairment and interference with the quality of life of the individual. If there is identification of CMD, it does not mean the certification of any diagnosis, but probable propensities and risk conditions for a mental illness¹.

Common Mental Disorders (CMD) are composed of non-psychotic depressive symptoms, anxiety and somatic complaints that influence the performance of daily activities. The symptoms that characterize this sphere are: problems of attention and memory, sadness, wakefulness, fatigue, neurasthenia, the presentiment of uselessness, somatic complaints, among others^1)(2)(5.

In general, 22.7% of the population had CMD (17.9% among men and 26.5% among women)(6). On the other hand, some studies with pregnant women, a slightly higher prevalence was identified, such as in Paraguay, where 33.6% of the participants presented CMD and in Recife (Brazil) the rate found was 43.1%⁷⁾⁽⁸.

The causes associated with CMD may be related to low level of education, older age, female, single or separated, not having employment/occupation and/or income, being smoker, alcoholic, sedentary and displeased with their body image.

Also, in the gestational period, risk factors for depression may be related to pregnancy in adolescence, unplanned pregnancy, negative feelings about pregnancy, being a single parent, having other children, having conflicts with her partner, not having social support, low income and low educational level¹⁾⁽².

There is not enough research in Brazil about depression during pregnancy, in which most of the depression was developed in a hospital environment and with pregnant adolescents, which shows predisposition in the evaluation of pregnant women at risk, being more prone to gestational depression⁴. It should also be noted that most studies did not use validated instruments to assess risk factors.

A study carried out with pregnant women assisted at the public service in the city of Pelotas identified a prevalence of 41.4% CMD associated with lower self-esteem². Also, in the southern region of Brazil, high rates of CMD were detected in pregnant women, and 41.7% of the sample had psychiatric disorder³.

In the city of Baixada Fluminense, Rio de Janeiro, the prevalence of depression during gestation and its association with social support and other risk factors by women assisted at the prenatal service in a basic health unit were estimated where depression was diagnosed in about one-fifth of these women. The prevalence of depression during pregnancy was 18%⁴.

Thus, this study is important because it allows to recognize mental illness during pregnancy, as well as to guide pregnant women and professionals about this problem. Thus, it will enrich the knowledge about the subject, by increasing studies in this field, especially in primary health care.

Therefore, the objective of the study was to analyze the occurrence of mental illness in pregnant women and to identify the factors associated with it.

METHOD

This is a cross-sectional study with a quantitative approach. It was opted for this approach because we understood that it best meets the proposed objectives.

The study was conducted at Family Health Units (FHU) in the urban area of Vitória de Santo Antão, Pernambuco, Brazil. The municipality has 15 health units in the urban area. Thus, 11 health units were selected for convenience.

The study population consisted of pregnant women enrolled in FHU. The exclusion criteria adopted was to be 18 years old or older. The pregnant women who presented difficulties to respond to the interview were excluded from the study. According to data obtained in the Basic Attention Information System (SIAB), in 2015, there were 516 pregnant women in the municipality⁹. For the sample calculation, the formula for finite population was used, with the following parameters: 95% confidence level, 7% error, and 41.4% prevalence estimation². Therefore, the sample was estimated in 141 participants. The participants were selected by non-probabilistic sampling process of the consecutive type and there were no losses.

The pregnant women were approached in the FHU before the prenatal visit and the interview was conducted in a private room in the unit, lasting approximately 10 minutes.

A questionnaire was used with identification data of the participants and a tool for screening for CMD, called "Self-Reporting Questionnaire" (SRQ-20). The identification questionnaire has questions about age, marital status, education level, family income, occupation, religion, number of inhabitants in the residence. Data on gestation and planning, pregnancy habits, chronic diseases such as diabetes and hypertension, alcohol and tobacco consumption, and family history of mental disorders were also collected.

The SRQ-20 is an instrument proposed by the World Health Organization for studies with the population in primary health care. It has twenty questions regarding the month before the interview. This instrument was validated in Brazil and allows identifying symptoms of the last thirty days. It has a good reliability, with Cronbach's alpha 0.86¹². It also enables to assess the risk (s) of mental illness for depression and anxiety¹⁰⁾⁽¹². The questionnaire allows affirmative or negative answers. The affirmative answer has the value of 1 and the negative answer has the value of zero. The sum of the scores of the answers composes the final score. A final score of 8 or more is considered a suspected case of mood disorder, anxiety and somatization, and 7 or less as an unsuspected case¹¹⁾⁽¹². In the study, the cut-off point of 8 was adopted.

The collected data were inserted in an Excel spreadsheet and analyzed using statistical software. Absolute and relative frequency were used, as well as the uncorrected chi-square test, chi-square test with Mantel-Haenzel extension and the chi-square test with yacht correction to analyze the association between illness mental and socio-demographic, gestational and health variables. P value <0.05 was used.

The study was approved by the Research Ethics Committee of the Federal University of Pernambuco (CAAE 64945317.1.0000.5208).

RESULTS

A total of 141 pregnant women participated in the study, most of them belonged to the age group less than 30 years old (82.98%), married (88.65%), studied until high school (61.7%), had family income of up to one minimum wage (70.92%), does not exercise paid activity (34.04%), Catholic (54.61%) and family group consisting of 3 to 5 people (55.32%).

It was also observed that most of the pregnant women in the study experienced the first pregnancy (42.55%), had not planned to become pregnant (71.63%), were in the second trimester of pregnancy (44.68%) and reported receiving the family support (95.74%), as can be seen inTable 1.

Table 1 Sociodemographic and gestational characterization of participants. Vitória de Santo Antão/PE, 2017 

Note:^*C.I.95% - Confidence interval at the level of significance of 95%

Source:Elaborated by the authors

Regarding the health conditions, most of the participants did not have a chronic disease (90.07%). Among those who had a chronic disease, most of them reported having hypertension (9.93%). Regarding the drug use, most of them did not use these substances (89.36%), and of the total number of users, tobacco was cited as the most consumed substance (5.67%). Also, most of the participants did not report a family history of mental disorder (69.5%). Among the participants who reported having a family history of mental disorder, depression was the most cited (16.31%).

Regarding the mental health of the pregnant woman, 31.9% (24.3-40.3) of the participants presented a suggestive picture of mental illness, while 68.1% (59.7-75.7) did not present indication of such illness.

Table 2and3show the sociodemographic, gestational and health variables associated with mental illness in the participants.

Table 2 - Sociodemographic factors associated with mental illness in pregnant women. Vitória de Santo Antão/PE, 2017 

Note:^*Chi-square test without correction

^**Trend chi-square test with Mantel-Haenszel extension.

^***Chi-square test with Yates correction. Note:^α- significantρ-value (<0.05)

Note:^α- significantρ-value (<0.05)

Source: Elaborated by the authors

Table 3 Gestational and health factors associated with mental illness in pregnant women. Vitória de Santo Antão/PE, 2017 

Note:^*Chi-square test without correction,

^**Trend chi-square test with Mantel-Haenszel extension.

^***Chi-square test with Yates correction. Note:^α- significantρ-value(<0.05)

Source:Elaborated by the authors

From the data presented inTables 2and3, it was identified that being single, having studied until elementary school, not having planned pregnancy and having chronic illness are associated with mental illness in pregnant women.

DISCUSSION

It was identified that 31.9% of the women presented a suggestive picture of mental illness, different from other studies, such as one study carried out in the city of Pelotas, which indicated that 41.4% of the participants had mental disorder², and another study in the south of Brazil with 41,7%³, and also a study performed in the city of Recife, which presented a rate of 43.1%⁸. Also, it is different from a research conducted in Rio de Janeiro, which identified mental disorder in 18% of the participants⁴. The results corroborate with a study in Paraguay, which described that 33.6% of the participants presented mental disorder⁷. Recently, another study conducted in the Central Region of Brazil found a prevalence of CMD in gestation of 57.1%¹³, which is higher than the result presented in this study. Differences in results may be related to the regional characteristics of the research places, as well as to the cut-off point adopted by the researchers.

When analyzing the sociodemographic factors, it was identified that the variables marital status and education level had an association with mental illness. Regarding marital status, it was observed in two studies with single people was associated with the suggestion of CMD in the pregnant state,²⁾⁽¹³which corroborates with this study, in which women living without the partner were more likely to have mental disorder when compared to married women. On the other hand, married women presented higher occurrences of CMD¹⁴.

Regarding the education level, it was verified in another study that low level of education, lower socioeconomic classification, and little family support are associated with a higher probability of having CMD².

No statistically significant association between mental illness and the variables age, income, occupation, religion, and family group was identified. However, other studies have identified an association between these variables and CMD, as a study with adolescents that identified association with age group¹. Another study pointed to an association between low self-esteem and a higher prevalence of CMD². Also, not working or studying; not living with the partner, and having two or more children presented significance with a probable mental disorder³. Besides these, research carried out in a basic health unit identified an association with being single, unemployed, and smoking⁴. In the women's health service, it was identified that the variables marital status, gestational age, and bleeding were associated with a common mental disorder¹³. Finally, family support, number of cigarettes smoked per day, alcohol consumption, use of daily medications, history of mental disorder, presence of marked events in the last 12 months and history of domestic violence were associated with depression during pregnancy¹⁵.

Regarding the gestational variables, it was observed that the number of gestations, gestational age, and family support did not show a statistically significant association with mental illness, which corroborates with research that showed that gestational age did not present a relation with mental illness in pregnancy and identified a higher risk of occurrence of mental disorder among primigravida¹⁵.

A statistically significant association in the planning for pregnancy was identified. The same finding was evidenced in another study carried out in a health service specialized in gynecological and obstetric care, located in the central region of Brazil in a medium-sized municipality of regional economic relevance¹³.

Regarding the health variables, it was verified that having chronic disease is associated with the suggestion of mental illness and occurs 3.2 times more than in pregnant women who do not have chronic disease. The chronic disease that was statistically significant was arterial hypertension (SAH). A literature review that aimed to know the relationship between arterial hypertension and emotional factors identified stress, anger, anxiety, and depression as factors for hypertension. It also described that stress contributes to the appearance of many diseases, both psychic and organic¹⁷.

The other variables related to health conditions, such as drug use and family history of mental disorder were not associated with mental illness in the participants of this study. Another research also did not identify an association between mental illness and psychiatric family history¹³. However, association between alcohol use and depression during pregnancy was identified in another study⁴.

The study had its accomplishment in small municipality, memory bias and the process of sampling for convenience as its limitations that portrays a certain place, which may limit the generalizations of the results. Therefore, it is suggested that studies can be carried out in municipalities with different population sizes and at random.

CONCLUSION

The study identified that 31.9% of pregnant women presented suggestion of mental illness, which is associated with being single, low level of education, not having planned pregnancy and having systemic arterial hypertension.

These results raise the attention to mental health issues at the time of the nursing visit and the nursing consultation during prenatal care. Looking at the pregnant woman and detecting the factors that increase her chances for mental illness will increase the professional's capacity for nursing care and, as a consequence, they should make the other phases of the nursing care process more assertive.

However, the results of this research were similar to those of other studies and showed that the Self-Reporting Questionnaire 20 instrument is easy to use for the screening of pictures suggestive of mental illness in pregnant women, which suggests its use in primary health care.