Abstract:

Although depression and anxiety are known to result in disabilities and workplace and health system losses, population-based studies on this problem are rare in Brazil. The current study assessed the prevalence of mental disorders in adolescents, youth, and adults and the relationship to sociodemographic characteristics in five birth cohorts (RPS) in Ribeirão Preto (São Paulo State), Pelotas (Rio Grande do Sul State), and São Luís (Maranhão State), Brazil. Major depressive episode, suicide risk, social phobia, and generalized anxiety disorder were assessed with the Mini International Neuropsychiatric Interview. Bootstrap confidence intervals were estimated and prevalence rates were stratified by sex and socioeconomic status in the R program. The study included 12,350 participants from the cohorts. Current major depressive episode was more prevalent in adolescents in São Luís (15.8%; 95%CI: 14.8-16.8) and adults in Ribeirão Preto (12.9%; 95%CI: 12.0-13.9). The highest prevalence rates for suicide risk were in adults in Ribeirão Preto (13.7%; 95%CI: 12.7-14.7), and the highest rates for social phobia and generalized anxiety were in youth in Pelotas, with 7% (95%CI: 6.3-7.7) and 16.5% (95%CI: 15.4-17.5), respectively. The lowest prevalence rates of suicide risk were in youth in Pelotas (8.8%; 95%CI: 8.0-9.6), social phobia in youth in Ribeirão Preto (1.8%; 95%CI: 1.5-2.2), and generalized anxiety in adolescents in São Luís (3.5%; 95%CI: 3.0-4.0). Mental disorders in general were more prevalent in women and in individuals with lower socioeconomic status, independently of the city and age, emphasizing the need for more investment in mental health in Brazil, including gender and socioeconomic determinants.

Keywords:
Mental Disorders; Cohort Studies; Socioeconomic Factors; Gender and Health; Life Cycle Stages

Introduction

Mental health promotion is considered a global priority as a key part of the agenda for the Sustainable Development Goals¹1. Lee BX, Kjaerulf F, Turner S, Cohen L, Donnelly PD, Muggah R, et al. Transforming our world: implementing the 2030 agenda through sustainable development goal indicators. J Public Health Policy 2016; 37:13-31.. Estimates indicate that one out of ten persons may have a current mental disorder and that one out of four will develop a mental disorder some time in life ²2. Izutsu T, Tsutsumi A, Minas H, Thornicroft G, Patel V, Ito A. Mental health and wellbeing in the Sustainable Development Goals. Lancet Psychiatry 2015; 2:1052-4.^,33. Tsutsumi A. Mental health, well-being and disability: a new global priority key United Nations resolutions and documents. Tokyo: United Nations University; 2015.. In 2016, mental disorders and behavioral substance use disorders affected more than a billion persons in the world, accounting for 7% of the global burden of disease and 19% of years lived with disability ⁴4. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet 2013; 382:1575-86.^,55. Rehm J, Shield KD. Global burden of disease and the impact of mental and addictive disorders. Curr Psychiatry Rep 2019; 21:10.. In Latin America and the Caribbean, mental and behavioral disorders, including those involving substance use, account for 10.5% of the global burden of disease, while in South America the prevalence of mental disorders in the previous 12 months was 17% ⁶6. Kohn R, Levav I, Almeida JMC, Vicente B, Andrade L, Caraveo-Anduaga JJ, et al. Los trastornos mentales en América Latina y el Caribe: asunto prioritario para la salud pública. Rev Panam Salud Pública 2005; 18:229-40..

In Brazil, regionally and nationally representative studies on mental health are scarce ⁷7. Munhoz TN, Nunes BP, Wehrmeister FC, Santos IS, Matijasevich A. A nationwide population-based study of depression in Brazil. J Affect Disord 2016; 192:226-33., but estimates from the late 1990s indicated that neuropsychiatric disorders accounted for 34% of all the morbidity, and that among the noncommunicable diseases, they were the leading cause of years of life lost to premature death or disability (disability-adjusted life year - DALY) ⁸8. Schramm JMA, Oliveira AF, Leite IC, Valente JG, Gadelha AMJ, Portela MC, et al. Epidemiological transition and the study of burden of disease in Brazil. Ciênc Saúde Colet 2004; 9:897-908.. According to recent estimates, mental disorders such as depression and anxiety are among the 10 leading causes of years of life with disability in Brazil ⁹9. Marinho F, de Azeredo Passos VM, Malta DC, França EB, Abreu DM, Araújo VE, et al. Burden of disease in Brazil, 1990-2016: a systematic subnational analysis for the Global Burden of Disease Study 2016. Lancet 2018; 392:760-75.. In various regions of the world, the exacerbation of social inequities has increased the prevalence of mental disorders ¹⁰10. McAllister A, Fritzell S, Almroth M, Harber-Aschan L, Larsson S, Burström B. How do macro-level structural determinants affect inequalities in mental health? A systematic review of the literature. Int J Equity Health 2018; 17:180.^,1111. Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, et al. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry 2018; 5:357-69.. In low and middle-income countries, environmental factors such as urban violence ¹²12. Ribeiro WS, Mari JD, Quintana MI, Dewey ME, Evans-Lacko S, Vilete LMP, et al. The impact of epidemic violence on the prevalence of psychiatric disorders in São Paulo and Rio de Janeiro, Brazil. PLoS One 2013; 8:e63545.^,1313. Silva M, Loureiro A, Cardoso G. Social determinants of mental health: a review of the evidence. Eur J Psychiatry 2016; 30:259-92. appear to aggravate inequities in mental health, especially in groups with the greatest risk of these traumatic events, like women and individuals with lower socioeconomic status.

Studies using standardized instruments to assess the prevalence of mental disorders at the population level are useful for elucidating their extent, assess trends, compare patterns, and quantify factors associated with their occurrence ¹⁴14. World Health Organization. Investing in mental health: evidence for action. Geneva: World Health Organization; 2013.^,1515. Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry 2015; 56:345-65.^,1616. Huang Y, Wang Y, Wang H, Liu Z, Yu X, Yan J, et al. Prevalence of mental disorders in China: a cross-sectional epidemiological study. Lancet Psychiatry 2019; 6:211-24.. This study aimed to describe the prevalence rates of depression, suicide risk, social phobia, and generalized anxiety disorder in adolescents, youth, and adults according to sociodemographic variables (sex, family income, and maternal schooling at birth) in five Brazilian birth cohorts that have been followed in different regions of Brazil.

Material and methods

Study design and sample characteristics

This study is based on data collected at birth in the Consortium of Birth Cohorts in Ribeirão Preto, Pelotas, and São Luís (the RPS Consortium), three geographically and socioeconomically distinct Brazilian cities. According to the Gini index, which reflects the degree of income concentration, in 2010, Ribeirão Preto (located in the state of São Paulo in Southeast Brazil) had the lowest social inequality score of the three cities, with 0.546, while Pelotas, located in the state of Rio Grande do Sul in the South, showed a Gini of 0.560, and São Luís, located in Maranhão in the Northeast, had the highest social inequality score, with 0.627 (Departamento de Informática do SUS. Índice Gini da renda domiciliar per capita segundo Município. http://tabnet.datasus.gov.br/cgi/ibge/censo/cnv/ginibr.def, accessed on 03/Jul/2019).

Data for Ribeirão Preto were taken from the waves at 37/39 years and 21/23 years of age, from the 1978/1979 and 1994 cohorts, respectively. In Pelotas, we included data from the visits at 30 years (1982 cohort) and at 18 and 22 years in the 1993 cohort. In São Luís, we analyzed data from the visit at 18/19 years of age in the 1997-1998 cohort. The terms adolescents, youth, and adults are used here to describe results for individuals under 19 years, from 21 to 23 years, and over 29 years of age, respectively.

In Pelotas, in 1982 and 1993, all the city’s maternity hospitals were visited daily and the newborns whose families lived in the urban area were examined and their mothers were interviewed ¹⁷17. Horta BL, Gigante DP, Goncalves H, dos Santos Motta J, Loret de Mola C, Oliveira IO, et al. Cohort profile update: the 1982 Pelotas (Brazil) birth cohort study. Int J Epidemiol 2015; 44:441-e.^,1818. Gonçalves H, Wehrmeister FC, Assunção MC, Tovo-Rodrigues L, Oliveira IO, Murray J, et al. Cohort profile update: the 1993 Pelotas (Brazil) birth cohort follow-up at 22 years. Int J Epidemiol 2017; 47:1389-90e.. In Ribeirão Preto, participants from the 1978-1979 cohort were also recruited at birth in the city’s eight maternity hospitals and their mothers were interviewed from June 1, 1978, to May 31, 1979.

From May to August 1994, births were recruited from the maternity hospitals in Ribeirão Preto ¹⁹19. Bettiol H, Barbieri MA, Gomes UA, Andrea M, Goldani MZ, Ribeiro ER. Saúde perinatal: metodologia e características da população estudada. Rev Saúde Pública 1998; 32:18-28.^,2020. Cardoso VC, Simões V, Barbieri MA, Silva AAM, Bettiol H, Alves M, et al. Profile of three Brazilian birth cohort studies in Ribeirão Preto, SP and São Luís, MA. Braz J Med Biol Res 2007; 40:1165-76.^,2121. Ferraro AA, Barbieri MA, Silva AAM, Goldani MZ, Fernandes MTB, Cardoso VC, et al. Cesarean delivery and hypertension in early adulthood. Am J Epidemiol 2019; 188:1296-303.. In São Luís, participants in the 1997-1998 cohort were recruited in 10 maternity hospitals from March 1, 1997, to February 28, 1998, using systematic sampling with probability of selection proportional to the number of births at each hospital, such that one out of seven live births in São Luís was selected for the study ²⁰20. Cardoso VC, Simões V, Barbieri MA, Silva AAM, Bettiol H, Alves M, et al. Profile of three Brazilian birth cohort studies in Ribeirão Preto, SP and São Luís, MA. Braz J Med Biol Res 2007; 40:1165-76.^,2222. Silva AAM, Coimbra LC, Silva RA, Alves MTSSB, Lamy Filho F, Lamy ZC, et al. Perinatal health and mother-child health care in the municipality of São Luís, Maranhão State, Brazil. Cad Saúde Pública 2001; 17:1412-23.^,2323. Silva AAM, Batista RFL, Simões VMF, Thomaz EBAF, Ribeiro CCC, Lamy-Filho F, et al. Changes in perinatal health in two birth cohorts (1997/1998 and 2010) in São Luís, Maranhão State, Brazil. Cad Saúde Pública 2015; 31:1437-50..

In all the birth cohorts, follow-up waves were conducted at different moments in the life cycle. Complete details on the studies’ methodology have been published previously ¹⁷17. Horta BL, Gigante DP, Goncalves H, dos Santos Motta J, Loret de Mola C, Oliveira IO, et al. Cohort profile update: the 1982 Pelotas (Brazil) birth cohort study. Int J Epidemiol 2015; 44:441-e.^,1818. Gonçalves H, Wehrmeister FC, Assunção MC, Tovo-Rodrigues L, Oliveira IO, Murray J, et al. Cohort profile update: the 1993 Pelotas (Brazil) birth cohort follow-up at 22 years. Int J Epidemiol 2017; 47:1389-90e.^,1919. Bettiol H, Barbieri MA, Gomes UA, Andrea M, Goldani MZ, Ribeiro ER. Saúde perinatal: metodologia e características da população estudada. Rev Saúde Pública 1998; 32:18-28.^,2020. Cardoso VC, Simões V, Barbieri MA, Silva AAM, Bettiol H, Alves M, et al. Profile of three Brazilian birth cohort studies in Ribeirão Preto, SP and São Luís, MA. Braz J Med Biol Res 2007; 40:1165-76.^,2222. Silva AAM, Coimbra LC, Silva RA, Alves MTSSB, Lamy Filho F, Lamy ZC, et al. Perinatal health and mother-child health care in the municipality of São Luís, Maranhão State, Brazil. Cad Saúde Pública 2001; 17:1412-23..

As for the study population in Pelotas, in the follow-up waves, we attempted to assess all participants from the 1982 and 1993 cohorts ¹⁷17. Horta BL, Gigante DP, Goncalves H, dos Santos Motta J, Loret de Mola C, Oliveira IO, et al. Cohort profile update: the 1982 Pelotas (Brazil) birth cohort study. Int J Epidemiol 2015; 44:441-e.^,1818. Gonçalves H, Wehrmeister FC, Assunção MC, Tovo-Rodrigues L, Oliveira IO, Murray J, et al. Cohort profile update: the 1993 Pelotas (Brazil) birth cohort follow-up at 22 years. Int J Epidemiol 2017; 47:1389-90e.. In Ribeirão Preto, we also attempted to assess all participants from the 1978-1979 and 1994 cohorts ²⁴24. Ferraz E, Garcia CA, Bettiol H, Caldeira RD, Cardoso VC, Arruda LK, et al. Fatores de risco para atopia no nascimento e na idade adulta. J Pediatr (Rio J.) 2011; 87:336-42.. In São Luís, participants from the 1997-1998 cohort were seen at 18/19 years, where part of the (613) came from the original cohort and the rest of the sample (1,886) consisted of an open cohort with individuals also born in that city in 1997 ²⁵25. Coelho SJDDAC. Nascimento de parto cesáreo, depressão e transtorno bipolar em adolescentes de uma coorte de nascimento, São Luís, MA [Dissertação de Mestrado]. São Luís: Universidade Federal do Maranhão; 2019..

Assessment of mental disorders

Mental disorders were assessed by previously trained professionals in all three sites of the RPS Consortium, using diagnostic modules from the Mini International Neuropsychiatric Interview (MINI), based on criteria from the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and of the International Classification of Diseases, 10th revision (ICD-10). In São Luís and Pelotas, only some modules of MINI were applied, while all the modules were used in Ribeirão Preto. This study assessed current and past major depressive episode (MDE), suicide risk, social phobia, and generalized anxiety disorder (GAD), since these disorders had data available from all the follow-up waves, and their presence was determined by preestablished algorithms in MINI ²⁶26. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 2018; 59:22-33..

Data analysis

Due to the low prevalence of some outcomes, the confidence intervals were estimated with bootstrap percentages with five thousand replications ²⁷27. Chernick MR, LaBudde RA. An introduction to bootstrap methods with applications to R. New Jersey: John Wiley & Sons; 2014.. This avoided negative values and loss of precision in the interval estimates. Thus, the different prevalence rates between the cities were assessed by inspecting the lower and upper limits of the estimated confidence intervals. Chi-square test was also used to assess the equality of proportions within each of the participating cities. Prevalence rates were stratified by family income (income tertiles), maternal schooling at birth (0-4 years; 5-8 years; 9-11 years; 12 and older) and sex (male and female). The R program, version 3.6.0 (http://www.r-project.org), was used for the statistical analyses, with significance set at 5%.

All participants signed a free and informed consent form. For those under 18 years of age, parents or guardians signed the form. Data collection was preceded by approval by the respective institutional review boards.

Results

Five birth cohorts were assessed at different life stages, two in Ribeirão Preto, two in Pelotas, and one in São Luís. In all, 12,350 individuals were included in the analyses: 4,055 from the 1993 cohort in Pelotas, 3,576 from the 1982 cohort in Pelotas, 2,499 from the 1997/1998 cohort in São Luís, 1,624 from the 1978/1979 cohort in Ribeirão Preto, and 596 individuals from the 1994 cohort in Ribeirão Preto.

Table 1 shows that prevalence rates for MDE were lower in the Pelotas cohorts, independently of age. Prevalence of current MDE was higher in adults in the 1982 cohort than in youth and adolescents from the 1993 cohort. In Ribeirão Preto, prevalence in adults was also higher than in youth. Regardless of the city and age, prevalence of current MDE was higher in women and in individuals with lower socioeconomic status.

Table 2 shows that past MDE was less prevalent in youth in Pelotas (2.4%; 95%CI: 1.9-2.8) and more prevalent in adults in Ribeirão Preto (7.7%; 95%CI: 7.0-8.4). Prevalence rates were higher in women, independently of age and city. For maternal schooling and income tertiles at birth, differences in prevalence rates for past MDE between the different categories were not clear.

Table 3 shows that suicide risk was similar between adolescents in São Luís (13.5%; 95%CI: 12.5-14.5) and Pelotas (12.9%; 95%CI: 12.0-13.9) and was also more prevalent in youth (13.4%; 95%CI: 12.5-14.4) and adults (13.7%; 95%CI: 12.7-14.7) from Ribeirão Preto, compared to youth (8.8%; 95%CI: 8.0-9.6) and adults (11%; 95%CI: 10.1-11.9) from Pelotas. Prevalence of suicide risk was higher in females and generally in those with lower socioeconomic status, independently of age and city. Exceptionally, among adolescents in São Luís, prevalence of suicide risk was higher when the mothers had 12 or more years of schooling.

As shown in Table 4, social phobia was less prevalent in youth (1.8%; 95%CI: 1.5-2.2) and adults (2.3%; 95%CI: 1.9-2.7) in Ribeirão Preto, while the highest rates were seen in youth (7%; 95%CI: 6.3-7.7) and adolescents (6.9%; 95%CI: 6.2-7.6) from the 1993 cohort in Pelotas. Social phobia was more prevalent in adolescents than in adults, while the prevalence rates did not differ between adolescents from São Luís and Pelotas. Except for youth in Ribeirão Preto, prevalence of social phobia was higher in women. It was even higher in individuals whose mothers had low schooling at birth, except among youth from Ribeirão Preto and Pelotas. As for family income, prevalence of social phobia was higher among individuals with lower socioeconomic status, except for adults in Ribeirão Preto.

Table 5 shows that prevalence of GAD was higher in youth in Pelotas (16.5%; 95%CI: 15.4-17.5) and lower in adolescents in São Luís (3.5%; 95%CI: 3.0-4.0). Prevalence rates were similar between adults in Ribeirão Preto (9.3%; 95%CI: 8.5-10.1) and Pelotas (10.4%; 95%CI: 9.5-11.2). Prevalence of this disorder was at least twice as high in women and was generally similar across socioeconomic strata. Unlike Pelotas and Ribeirão Preto, prevalence of GAD was higher in adolescents in São Luís whose mothers had 12 years or more of schooling.

Discussion

This was the first study on mental disorders combining data from different Brazilian birth cohorts, conducted with a similar methodology in different regions and at different ages. Our data not only reinforce the high rates of major depression, suicide risk, social phobia, and generalized anxiety as a public health problem, but also corroborate that these disorders vary according to the individual’s sex, place of occurrence, and socioeconomic status.

In general, prevalence rates for current and past MDE were lower in Pelotas than in Ribeirão Preto, while suicide risk varied little between the cities or according to age. Meanwhile, social phobia was more prevalent in Pelotas than in the other two cities, independently of age. GAD also differed between the cities, higher in Pelotas, especially among youth, and much higher in adolescents in São Luís. Female gender and lower socioeconomic status were related to higher prevalence rates for current MDE and suicide risk, independently of age and city.

Current MDE was considerably more frequent in adolescents in São Luís than in Pelotas at 18 years of age. Although we lack data on depression at later ages in São Luís, one hypothesis for this difference is that in São Luís, peak levels of this disorder occur after 16 years, similar to a pattern observed in other longitudinal studies with adolescents ²⁸28. Cyranowski JM, Frank E, Young E, Shear MK. Adolescent onset of the gender difference in lifetime rates of major depression: a theoretical model. Arch Gen Psychiatry 2000; 57:21-7.^,2929. Richardson LP, Davis R, Poulton R, McCauley E, Moffitt TE, Caspi A, et al. A longitudinal evaluation of adolescent depression and adult obesity. Arch Pediatr Adolesc Med 2003; 157:739-45.^,3030. Sutin AR, Terracciano A, Milaneschi Y, An Y, Ferrucci L, Zonderman AB. The trajectory of depressive symptoms across the adult life span. JAMA Psychiatry 2013; 70:803-11..

Meanwhile, in Pelotas and Ribeirão Preto, prevalence of current MDE was slightly higher in people in their thirties compared to younger people. A birth cohort in Dunedin, New Zealand, showed a similar pattern for this disorder, probably as a consequence of inherent uncertainties and difficulties in the transition from early adulthood to individuals’ thirties ³¹31. Moffitt TE, Harrington H, Caspi A, Kim-Cohen J, Goldberg D, Gregory AM, et al. Depression and generalized anxiety disorder: cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Arch Gen Psychiatr 2007; 64:651-60., when these rates tend to drop ³⁰30. Sutin AR, Terracciano A, Milaneschi Y, An Y, Ferrucci L, Zonderman AB. The trajectory of depressive symptoms across the adult life span. JAMA Psychiatry 2013; 70:803-11.^,3232. Clarke P, Marshall V, House J, Lantz P. The social structuring of mental health over the adult life course: advancing theory in the sociology of aging. Soc Forces 2011; 89:1287-313.. Considering the disorder’s severity and stability in the trajectory of the depressive symptoms at the individual level, there appears to be important heterogeneity and also different patterns in the disorder’s occurrence, depending on the region and context.

Regardless of age at follow-up, current and past MDE were less prevalent in Pelotas than in the other cities. This result may reflect not only individual etiological differences, but also intrinsic contextual differences in the study sites, as observed in other locations ¹⁰10. McAllister A, Fritzell S, Almroth M, Harber-Aschan L, Larsson S, Burström B. How do macro-level structural determinants affect inequalities in mental health? A systematic review of the literature. Int J Equity Health 2018; 17:180.^,3434. Rai D, Zitko P, Jones K, Lynch J, Araya R. Country-and individual-level socioeconomic determinants of depression: multilevel cross-national comparison. Br J Psychiatry 2013; 202:195-203.. The higher prevalence of current depression in adolescents in São Luís may reflect the region’s socioeconomic determinants, since São Luís, capital of the state of Maranhão, is located in the poorest region of Brazil and had the Lowest Human Development Index ³⁵35. Silva AA, Barbieri MA, Cardoso VC, Batista RF, Simões VM, Vianna EO, et al. Prevalence of non-communicable diseases in Brazilian children: follow-up at school age of two Brazilian birth cohorts of the 1990's. BMC Public Health 2011; 11:486. and the highest inequality of the three cities in the study (Departamento de Informática do SUS. Índice Gini da renda domiciliar per capita segundo Município. http://tabnet.datasus.gov.br/cgi/ibge/censo/cnv/ginibr.def, accessed on 03/Jul/2019).

The results for current MDE at the 18 and 22-year waves in the Pelotas 1993 cohort were similar to those reported in a population-based study in the same city using the same diagnostic instrument ³⁶36. Lopez Molina MA, Jansen K, Drews C, Pinheiro R, Silva R, Souza L. Major depressive disorder symptoms in male and female young adults. Psychol Health Med 2014; 19:136-45.. Munhoz e al. ⁷7. Munhoz TN, Nunes BP, Wehrmeister FC, Santos IS, Matijasevich A. A nationwide population-based study of depression in Brazil. J Affect Disord 2016; 192:226-33., using data from the Brazilian National Health Survey (PNS), which estimated depression with a different test, found that prevalence was higher in the South of Brazil (where Pelotas is located).

Due to the negative consequences associated with suicide risk, the high prevalence rates reported in this study are worrisome, independently of life phase and city. The most extreme consequence of suicide is obviously death, and suicide is a major cause of violent death in Latin America as a whole and in Brazil specifically, especially from 10 to 30 years of age ³⁷37. Ores LC, Quevedo LA, Jansen K, Carvalho AB, Cardoso TA, Souza LDM, et al. Risco de suicídio e comportamentos de risco à saúde em jovens de 18 a 24 anos: um estudo descritivo. Cad Saúde Pública 2012; 28:305-12.^,3838. Mascayano F, Irrazabal M, Emilia WD, Shah B, Vaner SJ, Sapag JC, et al. Suicide in Latin America: a growing public health issue. Rev Fac Cienc Méd 2016; 72:295-303.^,3939. Rodrigues CD, Souza DS, Rodrigues HM, Konstantyner TC. Trends in suicide rates in Brazil from 1997 to 2015. Braz J Psychiatry 2019; 41:380-8.. Suicide also frequently causes harm to persons close to the direct victim, including ideation, planning, suicide attempts, psychiatric morbidity such as depression, and/or physical health problems, further overloading health services, especially those providing mental healthcare ⁴⁰40. Spillane A, Matvienko-Sikar K, Larkin C, Corcoran P, Arensman E. What are the physical and psychological health effects of suicide bereavement on family members? An observational and interview mixed-methods study in Ireland. BMJ Open 2018; 8:e019472.. The high percentage of individuals with suicide risk in these studies thus has evident practical connotations, with the need to expand and qualify prevention strategies, mainly among youth, women, and socioeconomically vulnerable persons ⁴¹41. Bantjes J, Iemmi V, Coast E, Channer K, Leone T, McDaid D, et al. Poverty and suicide research in low-and middle-income countries: systematic mapping of literature published in English and a proposed research agenda. Glob Ment Health (Camb) 2016; 3:e32..

It was noteworthy that socioeconomic status did not appear to be clearly associated with prevalence of social phobia, which was higher in adolescents and relatively lower in adults, suggesting that this event peaks in adolescence. In Pelotas, prevalence at 18 and 22 years of age in the 1993 cohort, in which the data were collected outside the participants’ homes, was slightly higher than in a population-based study in the same city that found 4% prevalence in youth 18 to 24 years of age, using home interviews ³⁶36. Lopez Molina MA, Jansen K, Drews C, Pinheiro R, Silva R, Souza L. Major depressive disorder symptoms in male and female young adults. Psychol Health Med 2014; 19:136-45.. Among other possibilities, the discrepancy between the two studies could stem from methodological differences in the data collection.

Although social phobia can involve significant chronic psychosocial impairment and is among the most prevalent mental disorders in the general population, little is known about its life-course distribution and risk factors ⁴²42. Brunello N, Den Boer JA, Judd LL, Kasper S, Kelsey JE, Lader M, et al. Social phobia: diagnosis and epidemiology, neurobiology and pharmacology, comorbidity and treatment. J Affect Disord 2000; 60:61-74.^,4343. Eaton WW, Bienvenu OJ, Miloyan B. Specific phobias. Lancet Psychiatry 2018; 5:678-86.^,4444. Baptista CA, Loureiro SR, Lima Osório F, Zuardi AW, Magalhães PV, Kapczinski F, et al. Social phobia in Brazilian university students: prevalence, under-recognition and academic impairment in women. J Affect Disord 2012; 136:857-61.. Few studies have assessed its magnitude and associated factors in Brazil, generally limited to specific vulnerable groups such as university students, in whom its prevalence appears to be even higher, and with more evident harm in women ⁴⁴44. Baptista CA, Loureiro SR, Lima Osório F, Zuardi AW, Magalhães PV, Kapczinski F, et al. Social phobia in Brazilian university students: prevalence, under-recognition and academic impairment in women. J Affect Disord 2012; 136:857-61..

The low prevalence of GAD among adolescents in São Luís (3.5%) was surprising, especially when compared to adolescents in Pelotas, where it was nearly three times higher. Possible explanations for this discrepancy include cultural and regional differences in understanding the terms employed to characterize the symptoms listed in the MINI, besides a potential information bias. Although low prevalence rates are not rare in adolescents ⁴⁵45. Copeland WE, Angold A, Shanahan L, Costello EJ. Longitudinal patterns of anxiety from childhood to adulthood: the Great Smoky Mountains Study. J Am Acad Child Adolesc Psychiatr 2014; 53:21-33.^,4646. Abbo C, Kinyanda E, Kizza RB, Levin J, Ndyanabangi S, Stein DJ. Prevalence, comorbidity and predictors of anxiety disorders in children and adolescents in rural north-eastern Uganda. Child Adolesc Psychiatry Ment Health 2013; 7:21., in the general population the prevalence of anxiety disorders in the previous 12 months is nearly 10% ⁴⁷47. Remes O, Brayne C, Van Der Linde R, Lafortune L. A systematic review of reviews on the prevalence of anxiety disorders in adult populations. Brain Behav 2016; 6:e00497., similar to prevalence in the other two cities in this study, except at 22 years of age in Pelotas, where prevalence was 16.5%. Importantly, GAD estimated by MINI refers to the previous six months rather than to 12 months prior to the interview or even lifetime estimates, which are the time frames used in studies on GAD.

Beyond the inequalities in the prevalence of GAD, its co-occurrence with other mental disorders is not uncommon, especially with depression ⁴⁸48. Kessler RC, DuPont RL, Berglund P, Wittchen H-U. Impairment in pure and comorbid generalized anxiety disorder and major depression at 12 months in two national surveys. Am J Psychiatry 1999; 156:1915-23.^,4949. Möller H-J, Bandelow B, Volz H-P, Barnikol UB, Seifritz E, Kasper S. The relevance of 'mixed anxiety and depression' as a diagnostic category in clinical practice. Eur Arch Psychiatry Clin Neurosci 2016; 266:725-36.^,5050. Dold M, Bartova L, Souery D, Mendlewicz J, Serretti A, Porcelli S, et al. Clinical characteristics and treatment outcomes of patients with major depressive disorder and comorbid anxiety disorders-results from a European multicenter study. J Psychiatric Res 2017; 91:1-13.. The co-occurrence of GAD and depression tends to be associated with greater severity of the conditions, as well as lower response or treatment dropout and additional risk of suicide ⁵⁰50. Dold M, Bartova L, Souery D, Mendlewicz J, Serretti A, Porcelli S, et al. Clinical characteristics and treatment outcomes of patients with major depressive disorder and comorbid anxiety disorders-results from a European multicenter study. J Psychiatric Res 2017; 91:1-13.^,5151. van Bronswijk SC, Lemmens LH, Huibers MJ, Arntz A, Peeters FP. The influence of comorbid anxiety on the effectiveness of cognitive therapy and interpersonal psychotherapy for major depressive disorder. J Affect Disord 2018; 232:52-60..

In general, mental disorders assessed in this study showed considerably higher prevalence in women, across the three study sites and different age brackets, corroborating other studies showing differences between males and females in the occurrence of these mental disorders (higher in women) ³⁴34. Rai D, Zitko P, Jones K, Lynch J, Araya R. Country-and individual-level socioeconomic determinants of depression: multilevel cross-national comparison. Br J Psychiatry 2013; 202:195-203.^,5252. Kendler KS, Gardner CO. Sex differences in the pathways to major depression: a study of opposite-sex twin pairs. Am J Psychiatry 2014; 171:426-35.. Women’s greater susceptibility to depression and anxiety is still poorly understood, although frequently related to cultural and social determinants, as well as to neuroendocrine factors, especially the influence of sex hormones and their fluctuations ⁵³53. Rubinow DR, Schmidt PJ. Sex differences and the neurobiology of affective disorders. Neuropsychopharmacology 2019; 44:111.^,5454. Ma L, Xu Y, Wang G, Li R. What do we know about sex differences in depression: a review of animal models and potential mechanisms. Prog Neuropsychopharmacol Biol Psychiatry 2019; 89:48-56.. It is also possible that part of the excess in mental disorders among women in Brazil is explained by issues related to gender violence, whether or not perpetrated by the intimate partner. Recent studies in the states of São Paulo and Rio Grande do Sul have called attention to the high risk of violence against women, especially femicide ⁵⁵55. Margarites AF, Meneghel SN, Ceccon RF. Feminicídios na cidade de Porto Alegre. Quantos são? Quem são? Rev Bras Epidemiol 2017; 20:225-36.^,5656. Caicedo-Roa M, Cordeiro RC, Martins ACA, Faria PHD. Feminicídios na cidade de Campinas, São Paulo, Brasil. Cad Saúde Pública 2019; 35:e00110718.. In addition, the World Health Organization not only acknowledges violence against women as a public health problem with epidemic proportions, but also points to its consequences for mental disorders such as depression and anxiety, for example ⁵⁷57. World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization; 2013..

As for socioeconomic determinants, our results agree with those of other longitudinal studies that also point to educational levels and income as important determinants of adults’ mental health ⁵⁸58. Lorant V, Deliège D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: a meta-analysis. Am J Epidemiol 2003; 157:98-112.^,5959. Harper S, Lynch J, Hsu W-L, Everson SA, Hillemeier MM, Raghunathan TE, et al. Life course socioeconomic conditions and adult psychosocial functioning. Int J Epidemiol 2002; 31:395-403.^,6060. Quesnel-Vallée A, Taylor M. Socioeconomic pathways to depressive symptoms in adulthood: evidence from the National Longitudinal Survey of Youth 1979. Soc Sci Med 2012; 74:734-43.^,6161. Barros FC, Matijasevich A, Santos IS, Horta BL, Silva BGC, Munhoz TN, et al. Social inequalities in mental disorders and substance misuse in young adults. Soc Psychiatry Psychiatr Epidemiol 2018; 53:717-26.^,6262. Patel V, Burns JK, Dhingra M, Tarver L, Kohrt BA, Lund C. Income inequality and depression: a systematic review and meta-analysis of the association and a scoping review of mechanisms. World Psychiatry 2018; 17:76-89., especially in low and middle-income countries ⁶³63. Melchior M, Chastang J-F, Head J, Goldberg M, Zins M, Nabi H, et al. Socioeconomic position predicts long-term depression trajectory: a 13-year follow-up of the GAZEL cohort study. Mol Psychiatry 2013; 18:112.. These findings underline the need to improve these two components of socioeconomic status, which are associated mainly with suicide risk. It is also necessary to reduce inequities in access to mental health services ⁶⁴64. Ngui EM, Khasakhala L, Ndetei D, Roberts LW. Mental disorders, health inequalities and ethics: a global perspective. Int Rev Psychiatry 2010; 22:235-44., as observed in other countries.

One of this study’s strength was its large sample size, with more than 12 thousand individuals, as well as the comprehensive description of prevalence rates for mental disorders in birth cohorts from different regions of Brazil and in different stages of the life cycle. Besides, the five mental disorders were estimated with a similar instrument, allowing subsequent prospective analyses. However, the interpretation of this study’s results should take some limitations into account, such as non-standardization of the interviewers for data collection on mental disorders in the three cites, possibly leading to a measurement bias. Prevalence rates for mental disorders among adults from Pelotas and Ribeirão Preto may not have been directly or easily comparable, due to the time lapse of approximately eight years between the ages at follow-up. It is also impossible to rule out cultural/regional differences in the symptoms’ description (individual’s subjective report) and interpretation (by the interviewer), which could explain part of the observed differences in the estimates of mental disorders between the three sites.

Finally, the high prevalence of mental disorders underlines the need for more investment to deal with the problem in Brazil, especially in primary care ⁶⁵65. Gonçalves DA, Mari JJ, Bower P, Gask L, Dowrick C, Tófoli LF, et al. Brazilian multicentre study of common mental disorders in primary care: rates and related social and demographic factors. Cad Saúde Pública 2014; 30:623-32.^,6666. Onocko-Campos RT, Amaral CEM, Saraceno B, Oliveira BDC, Treichel CAS, Delgado PGG. Atuação dos Centros de Atenção Psicossocial em quatro centros urbanos no Brasil. Rev Panam Salud Pública 2018; 42:e113., providing access for users in different life stages and with specialized support for priority groups such as women with postpartum depression or victims of gender violence, as well as programs for suicide prevention among youth and adolescents ⁶⁷67. Centre for Mental Health; NHS Confederation Mental Health Network; Rethink Mental Illness; Turning Point. No health without mental health: implementation framework. London: Mental Health Strategy Branch; 2012.. The expansion and qualification of mental health services ⁶⁸68. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet 2011; 378:1592-603. not only reduces the burden of mental disorders on individuals, families, and the community, but also helps reduce avoidable expenditures in the health sector and prevent workforce losses ⁶⁷67. Centre for Mental Health; NHS Confederation Mental Health Network; Rethink Mental Illness; Turning Point. No health without mental health: implementation framework. London: Mental Health Strategy Branch; 2012.^,6868. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet 2011; 378:1592-603.^,6969. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007; 370:859-77.^,7070. Birnbaum HG, Kessler RC, Kelley D, Ben Hamadi R, Joish VN, Greenberg PE. Employer burden of mild, moderate, and severe major depressive disorder: mental health services utilization and costs, and work performance. Depress Anxiety 2010; 27:78-89.^,7171. Chesney E, Goodwin GM, Fazel S. Risks of all cause and suicide mortality in mental disorders: a meta-review. World Psychiatry 2014; 13:153-60..

Acknowledgments

The research project was partially financed by Wellcome 2009, grant 086974/Z/08/Z and the Graduate Studies Coordinating Board (Capes), funding code 001, and is currently financed by The Science of Technology Department, Brazilian Ministry of Health. São Paulo State Research Foundation (FAPESP); and Foundation for Support for Research and Scientific and Technological Development of Maranhão (FAPEMA).

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