Prevalence of psychiatric disorders in the first trimester of pregnancy and factors associated with current suicide risk

Psychiatry Research 210 (2013) 962–968

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Prevalence of psychiatric disorders in the first trimester of pregnancy and factors associated with current suicide risk Dayana Rodrigues Farias a,b, Thatiana de Jesus Pereira Pinto a,b, Marcella Martins Alves Teofilo a,b, Ana Amélia Freitas Vilela a,b, Juliana dos Santos Vaz a, Antonio Egidio Nardi c, Gilberto Kac a,b,n a Nutritional Epidemiology Observatory, Department of Social and Applied Nutrition, Institute of Nutrition Josué de Castro, Federal University of Rio de Janeiro, RJ, Brazil b Graduate Program in Nutrition, Institute of Nutrition Josué de Castro, Federal University of Rio de Janeiro, RJ, Brazil c Institute of Psychiatry, School of Medicine, Federal University of Rio de Janeiro, National Institute for Translational Medicine (INCT-TM), Brazil

art ic l e i nf o

a b s t r a c t

Article history: Received 9 March 2013 Received in revised form 6 August 2013 Accepted 29 August 2013

This study aimed to describe the prevalence of psychiatric disorders and to identify the factors associated with Current Suicide Risk (CSR) in the first trimester of pregnancy. The Mini-International Neuropsychiatric Interview (M.I.N.I.) was employed to diagnose mental disorders in 239 women enrolled in a prospective cohort in Rio de Janeiro, Brazil. Serum lipids, leptin and socio-economic status were the independent variables. CSR, the dependent variable, was entered as binary (yes/no) variable into crude and adjusted Poisson regression models with robust variances. CSR was found to be the main psychiatric syndrome (18.4%), followed by agoraphobia (17.2%), major depressive disorder (15.1%) and generalized anxiety disorder (10.5%). Women with CSR showed higher mean levels of cholesterol (169.2 vs. 159.2; p¼ 0.017), high density lipoprotein (50.4 vs. 47.7; p ¼0.031) and low density lipoprotein (102.8 vs. 95.6; p¼ 0.022) when compared to women without CSR. The adjusted regression model showed a higher prevalence ratio (PR) of CSR among pregnant women with generalized anxiety disorder (PR¼2.70, 95% CI: 1.36–5.37), with Ztwo parturitions (PR¼2.46, 95% CI: 1.22–4.93), and with major depressive disorder (PR¼ 2.11, 95% CI: 1.08–4.12). We have shown that generalized anxiety disorder, major depressive disorder and higher parity are associated with CSR in the first trimester of pregnancy. & 2013 Elsevier Ireland Ltd. All rights reserved.

Keywords: Suicide Depressive disorder Anxiety Agoraphobia Pregnancy Women Parity

1. Introduction The transition from pregnancy to motherhood is a unique life experience and can adversely affect women's psychological wellbeing (Bener et al., 2012). Depression and anxiety are among the most frequent mental disorders during and after pregnancy and may increase the risks of prolonged labor, low birth weight (LBW) and offspring malnutrition (Ishida et al., 2010; Nasreen et al., 2011; Bener et al., 2012). Among mental disorders, suicide behavior affects between 3% and 14% of the obstetric population (Lindahl et al., 2005; Pinheiro et al., 2012). Current suicide risk (CSR) includes thoughts and suicide attempts, and the likelihood of CSR is higher among depressed and anxious pregnant women compared to ones

n Correspondence to: Nutritional Epidemiology Observatory, Department of Social and Applied Nutrition, Institute of Nutrition Josué de Castro, Federal University of Rio de Janeiro, Avenida Carlos Chagas Filho, 373, CCS, Bloco J2. Cidade Universitária, Ilha do Fundão. Rio de Janeiro, RJ 21941-902, Brazil. Tel.: þ 55 2125626595; fax: þ 55 2122808343. E-mail address: [email protected] (G. Kac).

0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.08.053

without these disorders (Asad et al., 2010). CSR has been associated with adverse outcomes such as premature labor, LBW, cesarean section and postpartum depression (Chaudron et al., 2001; Gentile, 2011). Some studies have examined the combined effects of biological, lifestyle and social factors on the likelihood of suicide behavior during pregnancy. Factors such as violence between intimate partners, alcohol/drug abuse, being unmarried, unemployment, unintended pregnancy and a low level of social support have been associated with suicidal ideation (Pinheiro et al., 2012). Psychiatric disorders, such as major depressive disorder, panic disorder and generalized anxiety disorder, have also been reported as important determinants of suicide risk (Newport et al., 2007; Asad et al., 2010; Gavin et al., 2011). The association between suicide risk and biochemical parameters is still contradictory. Some studies with adults of both sexes have shown that lower serum total cholesterol (TC) and leptin concentrations are associated with suicide risk (Guillem et al., 2002; Atmaca et al., 2008; Olié et al., 2011), while other studies have found no association (Deisenhammer et al., 2004; Fiedorowicz and Coryell, 2007; D'Ambrosio et al., 2012). Although

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the biological mechanisms are not elucidated (Olié et al., 2011), it has been hypothesized that low TC could impair serotonin transportation to brain cells, which can increase suicide and impulsive aggressive-behaviors (Deisenhammer et al., 2004; Atmaca et al., 2008). Regarding leptin concentrations, it is suggested that it can increase the lipid oxidation and decrease the synthesis of triglycerides (TG) (Deisenhammer et al., 2004; Atmaca et al., 2008), which can lead to a decrease in the lipid concentration (Atmaca et al., 2008). It is well known that during pregnancy, there is an increase in serum concentrations of TC, TG and lowdensity lipoproteins (LDL), although the high-density lipoprotein (HDL) pattern is still unclear (Chiang et al., 1995; King, 2000; Landázuri et al., 2006; Benítez et al., 2010). To our knowledge, there have been no studies so far that have evaluated the association between lipid profiles or other biochemical parameters, such as leptin, and CSR during pregnancy. Thus, the aims of this study were to describe the prevalence of psychiatric disorders during the first trimester of pregnancy and to identify the factors associated with CSR.

2. Methods 2.1. Study protocol and design This study consists of a cross-sectional analysis of women in the first trimester of pregnancy who were enrolled in a prospective cohort and received prenatal care at a public health center in Rio de Janeiro, Brazil. The health center offers several different types of medical treatments. Recruitment was conducted between November 2009 and October 2011, and women who met the following eligibility criteria at enrollment were invited to participate: (1) being less than 13 weeks into the gestation period; (2) being between 20 and 40 years of age and (3) being free from any chronic diseases (except obesity, operationalized as a BMI Z 30 kg/m2). Of the women who were eligible, 93% (n¼ 299) agreed to participate. We excluded women who abandoned prenatal care (n¼ 6), presented twin pregnancies (n¼ 4), were diagnosed with an infectious or chronic disease in the baseline assessment (n¼ 14), were in use of antidepressant medication (n¼ 4), did not have completed Mini-International Neuropsychiatric Interview (M.I.N.I.) (n¼ 29) and reported miscarried before the baseline visit (n ¼3). After exclusions, the final sample comprised 239 women. A questionnaire pertaining to their socioeconomic status, obstetric history and lifestyle was administered. One-on-one interviews with the women were conducted by trained researchers in a private room.

2.2. Psychiatric assessment This study used the M.I.N.I. (version 5.0.0; Sheehan et al., 1998), a standard instrument consisting of a brief (15–30 min), structured interview to evaluate the existence of Axis I psychiatric disorders, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994). This instrument is divided into a variety of modules (A-P), each of which contains a series of questions pertaining to one the following psychiatric disorders: phobia episodes, major depressive episodes, generalized anxiety disorder, manic and hypomanic episodes, obsessive-compulsive disorder, panic disorders, dysthymic disorder, post-traumatic stress disorder, alcohol dependence and nonalcoholic substance dependence, bulimia and anorexia nervosa. The subjects answered yes or no to each of the questions. The interviews were performed by medical doctors and medical graduate students trained for this purpose.

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2.4. Independent variables A structured questionnaire was administered to measure the following independent variables: socioeconomic status, i.e., monthly per capita family income in tertiles of Brazilian currency (Reais); socio-demographic status, i.e., age (20–29, 30– 40 years), education ( Z 9, r 8 years), marital status (married or stable relationship, single), self-reported skin color (white, brown or black) and home density (number of people per bedroom: o 2, Z 2); lifestyle: current smoking habit (no, yes) and current alcohol consumption (no, yes); obstetric history: previous history of abortion (no, yes) and parity (0, 1, Z2); and mental health [questions pertaining to the following psychiatric disorders: major depressive episode (no, yes), agoraphobia (no, yes) and generalized anxiety disorder (no, yes)]. The occurrence of violence between intimate partners was measured using the Conflict Tactics Scales (CTS-1) (Hasselmann and Reichenheim, 2003). For the current analysis, the following variables were considered: verbal aggression (no, yes) and general physical aggression (no, yes). The social support construct was measured using a scale developed by the Medical Outcomes Study (MOS) (Griep et al., 2005). This scale consists of five social support dimensions: material (four questions), the provision of practical resources and material assistance; affective (three questions), physical demonstrations of love and affection; social and affective interaction (four questions), the presence of people with whom one can relax and enjoy oneself; emotional (four questions), the presence of a social network that satisfies emotional needs and provides encouragement during difficult moments in life; and informational, the presence of people who can advise, inform and guide (four questions). Social support was treated as a dichotomous variable, with a cutoff point based on the lower quartile: material ( 4 60, r60), affective (Z 86.7, o 86.7), interaction ( 470,r70), emotional ( 467.5, r 67.5) and informational ( Z 70, o 70). Additionally, women were asked questions about the number of close friends they had (0–1, Z2), the number of close relatives they had (0–1, Z 2), their family (first-degree relative) history of depression (no, yes) and their family (first-degree relative) history of suicide (no, yes). Data for these variables were obtained through the following questions: “How many relatives do you feel comfortable to talk with about almost everything?”; “How many friends do you feel comfortable to talk with about almost everything?”; “In your family, is there someone who suffers from depression or has ever suffered from depression in the past (only first-degree relatives)?”, and “In your family, is there a history of suicide (only first-degree relatives)?”. The women were weighed using a digital scale (Filizola Ltd., São Paulo, Brazil) in the first trimester ( r 13 gestational weeks), and their stature was measured twice using a Seca Portable Stadiometer (Seca Ltd., Hamburg, Germany). All anthropometric measurements were conducted in a standardized manner and taken by trained interviewers. Weight gain during first trimester varies around 0.5– 2 kg and may be considered small (Krasovek and Anderson, 1991; IOM, 2009). Furthermore, women's pre-pregnancy Body Mass Index (BMI) classifications using the measured weight in the first trimester when compared to the self-reported prepregnancy weight revealed a high kappa coefficient [0.86 (95CI%: 0.81–0.90)] according to a very recent study (Holland et al., 2012). Thus, BMI (weight [kg]/ stature [m2]) measured between the 5th and 13th weeks of pregnancy was used as pre-pregnancy BMI. This study used the cutoff points proposed by the Institute of Medicine (IOM, 2009) to classify the initial nutritional status of the women.

2.5. Blood sample analysis Blood samples were collected after a fast of 12 h. The samples were centrifuged at 1500g for 5 min. Plasma and serum samples were separated and stored at  80 1C until analysis was performed. Serum TC (mg/dL) and TG (mg/dL) levels were assessed using the Trinder enzymatic colorimetric methods, and high-density lipoprotein cholesterol (HDL; mg/dL) was assessed using the enzymatic colorimetric-accelerator selective detergent method (LabtestDiagnostica S.A., Brazil). LDL (mg/dL) was then calculated (Friedewald et al., 1972). Plasmatic leptin concentration (ng/dL) was measured with the ELISA method using commercial kits (Linco Research, St. Charles, Missouri, USA).

2.6. Statistical analysis 2.3. Current suicide risk CSR was assessed based on the ‘suicidality’ level obtained from the M.I.N.I. This module contained six questions, and positive answers received a unique score as follows: “In the past month did you (1) think that would be better off dead or wish you were dead? (Score¼ 1); (2) want to harm yourself or to hurt or to injure yourself? (Score¼2); (3) think about suicide? (Score¼ 6); (4) have a suicide plan? (Score¼10); (5) attempt suicide? (Score¼ 10)” and “(6) In your lifetime, have you ever made a suicide attempt? (Score¼ 4)”. Based on this instrument, level of suicidality was defined as low (1–5), moderate (6–9) or high (Z 10). CSR (no/yes) was the dependent variable, and a participant who gave a positive answer to at least one of these questions was considered to have a positive CSR.

The data were entered twice using the Census and Survey Processing System (CSPro) software, version 4.1.002. Consistency was checked to correct systematic errors. The statistical analyses were performed in STATA, version 10.1. The prevalence of each diagnosed psychiatric disorder was evaluated first. Subsequently, the sample was characterized by calculating the absolute and relative frequencies of CSR, based on all of the independent variables. The strengths of association were estimated in terms of crude and adjusted prevalence ratios (PR) and their respective 95% confidence intervals (CI) using Poisson's regression with robust variance. Variables with p-values o 0.20 were added into the multiple regression model. In the final model, the level of statistical significance was set at 5% (po 0.05). The mean and median values of the lipid variables were compared using the t-test and the Mann–Whitney U test, respectively.

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2.7. Ethics approval

4. Discussion

The study protocol was approved by the research ethics committee of the Institute of Psychiatry of the Rio de Janeiro Federal University (CAAE: 0012.0.249.000-09) and the Municipal Secretary of Health of the Rio de Janeiro Municipality (CAAE: 0139.0.314.000-09). All participants freely signed a two-way consent form after all necessary instructions and clarifications had been provided.

The results from the present study revealed a high prevalence of CSR (18.4%), agoraphobia (17.2%), major depressive disorder (15.1%) and generalized anxiety disorder (10.5%) during the first trimester of pregnancy. Women with CSR presented higher mean levels of TC, HDL and LDL compared to those without CSR; however, no differences were observed for TG and leptin levels between women with and without CSR. Finally, and more importantly, the multivariate Poisson regression model revealed that women with two or more parturitions, with generalized anxiety disorder and with major depressive disorder were more likely to have CSR than those without these factors. The prevalence of CSR observed in the current study is higher than reported in previous studies among Brazilian pregnant women. Huang et al. (2012) reported a 6.3% prevalence of suicidal ideation, as assessed by the Self-Report Questionnaire-20 (SRQ20), in a sample of women between 20 and 30 weeks of pregnancy, living in the city of São Paulo. Da Silva et al. (2012) observed a 8.1% prevalence of suicidal ideation, based on item 10 of the EPDS, in a cross-sectional study of pregnant women whose gestational weeks varied and who received care from a public health service in Pelotas, southern Brazil. The lower prevalence of suicidal ideation observed in these two studies with respect to that observed in ours can be explained by the methods used to diagnose CSR. We used the M.I.N.I. psychiatric assessment, which is composed of four components related to suicidality, whereas the other studies were based on a single item. A lower prevalence of CSR (13.3%) using the M.I.N.I. was identified by Pinheiro et al. (2012) in a group of high-risk pregnant women (teenagers) in southern Brazil. Our findings regarding major depressive disorders are in line with those of a recent systematic review covering 17 low- to middle-income countries that estimated the average prevalence of gestational depression to be 15.6% (95% CI: 15.4–15.9) (Fisher et al., 2012). A review of Brazilian studies showed that the prevalence of gestational depression ranges from 8.1% to 37.9%, with an average of 20% in low-income samples (Pereira and Lovisi, 2008). This wide variation may be attributed to the use of different methodologies for assessing depression, i.e., most studies used a scale to measure depressive symptoms instead of a diagnostic instrument. We have identified only one study that has measured agoraphobia during pregnancy. Zar et al. (2002) studied 104 pregnant Swedish women with potential anxiety disorders or a severe fear of childbirth and found a very low prevalence of agoraphobia (1.9%). However, differences in regards to the socio-economic and cultural backgrounds between the Swedish sample and our study prevent comparisons. Our results can potentially be explained by the presence of an associated syndrome that is composed of several co-morbidities, including suicide risk, depression and generalized anxiety, a syndrome that is associated with clinical problems during pregnancy, or other negative factors, such as the risk of violence in the home. In addition, these results may be a consequence of using the M.I.N.I. instrument, which provides a simple diagnosis and might not catch mild cases or false positives. The high values observed in our study are in line with other studies conducted among Brazilians that employed the M.I.N.I. instrument (Nascimento et al., 2002; Veras et al., 2006), but higher than others (Rassi et al., 2010). The results of the final multivariate Poisson regression revealed that major depressive episodes and generalized anxiety were associated with CSR. Many studies have reported the association between depression, anxiety and suicide during pregnancy (Lindahl et al., 2005; Asad et al., 2010; Howard et al., 2011; da Silva et al. 2012; Pinheiro et al., 2012). da Silva et al. (2012) found similar results to ours in a sample of 1334 Brazilian pregnant

3. Results The sample consisted of 239 pregnant women with a mean age of 26.7 (S.D. ¼5.4) years and 8.8 (S.D. ¼ 2.9) years of education. Most women reported being in a stable relationship (79.1%), not smoking (92.9%), and not consuming alcohol (80.3%). The mean pre-pregnancy BMI was 25.2 kg/m2 (S.D. ¼4.8), and the mean parity was 1.0 (S.D. ¼1.1). CSR was the main psychiatric syndrome affecting 18.4% of the women, followed by agoraphobia (17.2%), major depressive disorder (15.1%) and generalized anxiety disorder (10.5%). The prevalence of all other psychiatric disorders was lower than 5% (Table 1). Unadjusted prevalence ratios revealed that CSR was more prevalent among women with major depressive disorder (44.4%, PR ¼3.22, 95% CI: 1.74–5.95), agoraphobia (34.2%, PR ¼2.25, 95% CI: 1.19–4.25) and generalized anxiety disorder (56.0%, PR ¼3.99, 95% CI: 2.12–7.53), as well as for those with 2 or more parturitions (34.6%, PR ¼ 2.49, 95% CI: 1.36–4.54), those who reported regular use of alcohol during pregnancy (31.9%, PR ¼ 2.11; 95% CI: 1.13– 3.94), single women (32.0%, PR ¼ 2.16, 95% CI: 1.17–4.00) and those who had suffered from general physical violence (26.0%, PR ¼2.00, 95% CI: 1.07–3.72) (Table 2). Women with CSR showed higher means of CT (169.2 vs. 159.2; p ¼0.017), HDL (50.4 vs. 47.7; p¼ 0.031) and LDL (102.8 vs. 95.6; p ¼0.022) compared to those without CSR (Table 3). The final Poisson regression model showed a higher prevalence ratio of CSR among pregnant women with generalized anxiety disorder (PR ¼2.70, 95%CI: 1.36–5.37), two or more parturitions (PR ¼2.46, 95% CI: 1.22–4.93), and major depressive disorder (PR ¼2.11, 95% CI: 1.08–4.12). The results were adjusted for age, years of education, monthly per capita family income and marital status (Table 4). Table 1 Diagnosis according to Mini-International Neuropsychiatric Interview in women during the first trimester of pregnancy who attended prenatal care in a public health center in Rio de Janeiro, Brazil, 2009–2012 (n¼ 239). Variables

n

%

Suicide risk (current) Low Moderate High Agoraphobia Major depressive disorder Generalized anxiety disorder Social phobia Alcohol dependence Obsessive–compulsive disorder Mania Dysthymic disorder Hypomania Post-traumatic stress disorder Nonalcoholic substance dependence Panic disorder Bulimia nervosa Alcohol abuse Nonalcoholic substance abuse Anorexia nervosa

44 29 3 12 41 36 25 11 10 8 7 6 6 4 3 1 2 1 1 1

18.4 12.1 1.3 5.0 17.2 15.1 10.5 4.6 4.2 3.4 2.9 2.5 2.5 1.7 1.3 0.4 0.8 0.4 0.4 0.4

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Table 2 Absolute and relative frequencies, and prevalence ratio (PR) of current suicide risk in women at first trimester of pregnancy who attended prenatal care in a public health center in Rio de Janeiro, Brazil, 2009–2012 (n ¼239). Variables

N

Frequency (%)

Current suicide risk n

Prevalence (%)

PR (95% CIa)

p-Valueb

Socio-demographic characteristics Age (years) 20–29 167 30–40 72

69.9 30.1

29 15

17.4 20.8

1.0 1.20 (0.64–2.24)

0.567

Education (years) Z9 r8

138 101

57.7 42.3

24 20

17.4 19.8

1.0 1.14 (0.63–2.06)

0.668

Monthly per capita family income (tertile) 3rd 80 2nd and 1st 156

33.9 66.1

9 35

11.3 22.4

1.0 1.99 (0.96–4.15)

0.065

Marital status Married or stable partnership Single

189 50

79.1 20.9

28 16

14.8 32.0

1.0 2.16(1.17–04.00)

0.014

Self-reported skin color White Mixed brown Black

61 115 63

25.5 48.1 26.4

9 21 14

14.8 18.4 22.2

1.0 1.24 (0.57–2.70) 1.51 (0.65–3.48)

0.592 0.338

Home crowding (persons/dorms) 0–1 Z2

157 76

67.4 32.6

22 21

14.0 27.6

1.0 1.97 (1.08–3.58)

0.026

Life-style Smoking habit (current) No Yes

222 17

92.9 7.1

40 4

18.0 23.5

1.0 1.30 (0.47–3.65)

0.652

Alcohol consumption (current) No Yes

192 47

80.3 19.7

29 15

15.1 31.9

1.0 2.11 (1.13–3.94)

0.019

Obstetric history Parity 0–1 Z2

187 52

78.2 21.8

26 18

13.9 34.6

1.0 2.49 (1.36–4.54)

0.003

Previous history of abortion No Yes

105 57

64.8 35.2

20 16

19.0 28.0

1.0 1.47 (0.76–2.84)

0.248

Mental health Reported family history of depression No 174 Yes 61

74.0 26.0

31 11

17.8 18.0

1.0 1.01 (0.51–2.01)

0.973

Reported family history of suicide No Yes

226 13

94.6 5.4

41 2

18.1 15.4

1.0 0.85 (0.20–3.50)

0.820

Major depressive disorder (current) No Yes

203 36

84.9 15.1

28 16

13.8 44.4

1.0 3.22 (1.74–5.95)

o0.001

Agoraphobia No Yes

198 41

82.9 17.1

30 14

15.2 34.2

1.0 2.25 (1.19–4.25)

0.012

Generalized anxiety disorder No Yes

214 25

89.5 10.5

30 14

14.0 56.0

1.0 3.99 (2.12–7.53)

o 0.001

Violence between intimate partners Verbal aggression No 10 Yes 221

4.3 95.7

1 39

10.0 17.7

1.0 1.76 (0.24–12.84)

0.575

General physical violence No Yes

154 77

66.7 33.3

20 20

13.0 26.0

1.0 2.00 (1.07–3.72)

0.028

Social support Number of close relatives Z2 0–1

141 95

59.8 40.2

23 20

16.3 21.0

1.0 1.29 (0.71–2.35)

0.404

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D.R. Farias et al. / Psychiatry Research 210 (2013) 962–968

Table 2 (continued ) N

Variables

Frequency (%)

Current suicide risk n

Prevalence (%)

PR (95% CIa)

p-Valueb

48.7 51.3

18 25

15.7 20.7

1.0 1.32 (0.72–2.42)

0.369

Social support scale—dimensions scores Material 460 176 r 60 63

73.6 26.4

30 14

17.0 22.2

1.0 1.30 (0.69–2.46)

0.413

Affective Z 86.7 o 86.7

160 77

67.5 32.5

24 19

15.0 24.7

1.0 1.64 (0.90–3.00)

0.105

Emotional 467.5 r 67.5

178 59

75.1 24.9

28 15

15.7 25.4

1.0 1.62 (0.86–3.02)

0.134

Interaction Z 70 o 70

177 60

74.7 25.3

28 15

15.8 25.0

1.0 1.58 (0.84–3.00)

0.153

Information Z 80 o 80

187 50

78.9 21.1

31 12

16.6 24.0

1.0 1.450 (0.74–2.81)

0.276

Nutritional status Pre-pregnancy BMIc (kg/m²) o 25 Z 25

138 100

58.0 42.0

21 23

15.2 23.0

1.0 1.51 (0.84–2.73)

0.171

Number of close friends Z2 0–1

a b c

115 121

CI: confidence interval. p-Values refers to the likelihood ratio test. BMI: body mass index.

Table 3 Differences between serum biochemical parameters of women during the first trimester of pregnancy with and without current suicide risk who attended prenatal care in a public health center in Rio de Janeiro, Brazil, 2009–2012 (n ¼237a). Biochemical parameters

Total cholesterol (mg/dL) HDL-cholesterol (mg/dL) LDL-cholesterol (mg/dL)

Triglycerides (mg/dL) Leptin (ng/dL) a b c

Current suicide risk Present (n¼ 44) Mean (standard deviation)

Absent (n¼193a) Mean (standard deviation)

p-Value

169.2(30.7) 50.4 (8.2) 102.8(23.2)

159.2 (27.7) 47.7(8.7) 95.6 (20.8)

0.017 0.031 0.022

Median (minimum  maximum)

Median (minimum  maximum)

p-Valuec

77.0 (29.0–159.0) 20.9 (2.8–115.6)

73.0 (33.0–223.0) 16.8 (2.6–81.5)

0.569 0.116

b

Two subjects had not provided blood samples. p-Value refers to the Student t test p-Value refers to the Mann–Whitney U test.

women with mean of 25 years of age (S.D. ¼6.5). In this study, women with depression and anxiety disorders were 3.83 and 10.05 times more likely, respectively, to have suicide ideation. In our study women with 2 or more parturitions were 2.46 times more likely to have CSR. We did not found studies that evaluated this association with CSR and just a few have included parity in the investigation of suicidal ideation. Howard et al. (2011) observed an extremely high likelihood of suicidal ideation (Odds ratio ¼15.06, 95% CI: 1.55–146.5) for British women with three of more parturitions. By contrast, Høyer and Lund (1993), based on a prospective study with 989,949 parous women, found a lower relative risk of suicide when compared to non-parous women. In addition, a recent study by Yang (2010) reported that women with three or more parturitions had a 60% lower likelihood of suicide compared to those with only one child, even after adjusting the

analysis for several confounding factors. The goal of these studies was to find empirical support for parenthood. As shown, the association between parity and suicidal ideation is not completely clear. We advocate that parity might have a bi-directional effect on suicide. We expect that, for our current sample of women, a lowincome and low level of education may generate a high level of stress, which can contribute to an increase in the likelihood of suicidal ideation. In the current study, we found higher mean levels of TC, HDL and LDL in the first trimester of pregnancy in women with CSR when compared with those without CSR, and no association for TG and leptin. The relation between low serum concentrations of lipids and different suicide measures has received much attention (Guillem et al., 2002; Atmaca et al., 2008; Olié et al., 2011). Some studies have hypothesized that low lipids concentrations can

D.R. Farias et al. / Psychiatry Research 210 (2013) 962–968

Table 4 Factors associated with current suicide risk in women during the first trimester of pregnancy, who attended prenatal care in a public health center in Rio de Janeiro, Brazil, 2009–2012 (n ¼236a). Variables

PR (95% CI)

p-Valueb

Generalized anxiety disorder No Yes

1.0 2.70 (1.36–5.37)

0.005

Parity 0–1 Z2

1.0 2.46 (1.22–4.93)

0.011

Major depressive disorder No Yes

1.0 2.11 (1.08–4.12)

0.028

a

Three subjects did not report monthly per capita family income. p-Values refer to the likelihood ratio test and were adjusted for age, years of education, monthly per capita family income and marital status. b

impair serotonergic system increasing suicide and impulsive aggressive-behaviors (Deisenhammer et al., 2004; Atmaca et al., 2008). However, this association remains unclear and contradictory. Fiedorowicz and Coryell (2007), for example, found that high cholesterol levels were associated with an increased risk of suicide attempts in a survival analysis of a sample of adults under 32 years old who met the diagnostic criteria for major depressive disorder, mania, or schizoaffective disorder. By contrast, AlmeidaMontes et al. (2000) studied 33 patients diagnosed with a major depressive episode and found no significant differences in the serum concentrations of serum TC, HDL, LDL and TG between the group that attempted suicide and the group that did not. To our knowledge this is the first study relating lipid measures with CSR in pregnant women from low-income countries and for this reason comparisons cannot yet be made. The present study has some strengths that must be highlighted. The mental health assessment was performed using the M.I.N.I., which is a validated psychiatric instrument. Most studies that have investigated suicidality during pregnancy were based on a single item pertaining to suicidal ideation from a regular psychiatric scale that is usually employed in screening for depression or anxiety, such as the Edinburgh Postnatal Depression Scale – EPDS (da Silva et al., 2012; Pinheiro et al., 2012), the Patient Health Questionnaire – PHQ (Gavin et al., 2011), the Beck Depression Inventory – BDI (Newport et al., 2007), or the Hamilton Rating Scale for Depression —HRSD (Newport et al., 2007). An additional strength was the inclusion in the analysis of several variables that are known to be associated with CSR. A drawback of the study is its cross-sectional design, which prevents us from establishing causality. In addition, the study's sample was composed mainly of low-income women who received prenatal care at a public health center, which somewhat limits the external validity of the results. In conclusion, CSR, agoraphobia, major depressive disorder and anxiety were highly prevalent during the first trimester of pregnancy in this group of Brazilian women. Furthermore, women with CSR presented higher mean levels of TC, HDL and LDL when compared to those without CSR. We also observed that women with two or more parturitions, with generalized anxiety disorder and with major depressive disorder were more likely to have CSR than those without these factors. These results have shown that mental disorders are important public health problems during the first trimester of pregnancy in this group of women. References Almeida-Montes, L.G., Valles-Sanchez, V., Moreno-Aguilar, J., Chavez-Balderas, R.A., García-Marín, J.A., Cortés-Sotres, J.F., Hheinze-Martin, G., 2000. Relation of

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