INTRODUCTION

Adolescence is a very important period in the lives of individuals, since it is during this period that significant changes occur in the biological, psychological, social and intellectual fields. The World Health Organization (WHO) defines adolescence as the period between 10 and 20 years of age(30).

Due to rapid advances in medicine, an increasing number of chronically ill adolescents have had their lives extended and, in addition, their lives have been more active and productive than they would have been a few decades ago(7,19).

Today, there is a very large number of adolescents living with some type of chronic pathology and, probably, the way an adolescent experiences chronic illness is very different from that of a child or an adult. If it is sometimes difficult for an adolescent without an illness to experience all the changes that occur in his or her body, what can we say about a young person who has to live through them while facing a pathology that often causes deformities, frequent physical suffering and changes in his or her daily life?

Neinstein(22) defines chronic diseases as those that present permanent or residual disability, an irreversible pathological change or that require prolonged periods of supervision, observation, care and/or rehabilitation.

According to Gortmaker and Sappenfield(14), who conducted a study to assess the prevalence and impact of chronic diseases in childhood, approximately nine out of ten children with chronic diseases survive, in industrialized countries, until at least 20 years of age. This survival has led to an increase in the number of adolescents who require special care, as well as a reasonable number of studies in the literature on the subject.

Large-scale epidemiological studies have indicated that by the age of 15, approximately one in ten adolescents has some chronic disease(26).

Neinstein(22) points out that 10% to 20% of adolescents have some chronic condition and that more accurate data are difficult to obtain, since the prevalence rates of some chronic pathologies vary as they become more easily treatable.

In recent decades, the number of studies evaluating mental disorders in the general population has increased. Among them, the most important were conducted in Western countries and demonstrated that 90% of psychiatric morbidity in these populations consists of non-psychotic disorders, the main ones being depression and anxiety, including a series of nonspecific and somatic complaints(1,8,10).

Most studies in this area have reported difficulties generated by methodological and conceptual issues regarding the distinction between depressive and anxiety disorders, especially in the general population. This occurs due to the diagnostic model used in these studies, which is based on nosological categories, presenting criteria that non-psychotic mental disorders do not fit into.

From a theoretical point of view, minor mental disorders such as depression and anxiety tend to generate great controversy(2,21). The nature and classification of these disorders have given rise to discussions about whether they are diseases or types of reactions; independent entities or arbitrary concepts; and whether their classification should be made according to symptomatology, etiology or pathogenesis(17).

The difficulty in distinguishing between depressive and anxiety disorders, combined with the fact that non-psychotic disorders share several symptoms, makes the use of the diagnostic model based on nosological categories problematic(9,16,18). In this sense, several studies have used a broader classification, referred to as common mental disorders (CMD). This category encompasses non-psychotic psychiatric disorders, with the exception of drug abuse/dependence and conduct disorders(5,8,20).

The main studies conducted on the subject of adolescence and chronic diseases , aiming to observe disorders in the field of mental health, have been carried out with the intention of offering professionals who deal with these special patients a greater understanding of the universe of chronically ill adolescents(4,19,23,27,29).

Controversy has been observed among the various studies conducted on the subject regarding the mental disorders that occur in chronically ill adolescents. Some demonstrate that there is a higher incidence of mental disorders among adolescents with chronic diseases compared to those who do not present such conditions(3,15,23,29). Other studies disagree and do not find a higher incidence of such disorders among chronically ill adolescents compared to those without such conditions(4,24).

The general objective of this article is to estimate the prevalence of CMD (depression and anxiety) in a population of chronically ill adolescents regularly treated at a specialized outpatient clinic located in a university hospital in the state of Rio de Janeiro. It also aims to estimate the degree of association of certain conditions, such as type of chronic disease, time of evolution and presence of associated pathologies, with the presence of CMD.

METHODOLOGY

This was a cross-sectional study to determine the prevalence of minor psychiatric morbidity in a population of chronically ill adolescents. The source population consisted of patients between 12 and 20 years of age, inclusive, regularly enrolled and treated at specific secondary care outpatient clinics for cardiology, nephrology, rheumatology, arterial hypertension, and allergy at an adolescent outpatient clinic located at a university hospital in the state of Rio de Janeiro, who presented chronic diseases according to the definition of Neinstein(22). Exclusion criteria were those that could prevent the application of the General Health Questionnaire (GHQ-12), such as severe neurological injuries and some acute and chronic psychiatric conditions that evidenced severe cognitive impairment in language or communication. The study population consisted of all patients with chronic diseases treated at the outpatient clinics of interest during the six-month period (May to October 2001, inclusive).

An instrument was developed to extract data from patients’ medical records and their respective first-time forms. From this, which is filled out when patients come for their first clinical appointment at the outpatient clinic, demographic data such as gender, age, education level and family income were obtained. Information regarding chronic pathologies was collected from the medical records of the respective outpatient clinics, such as time of disease progression and whether there are other associated pathologies, chronic or not.

To assess CMDs, the necessary information was obtained through the application of the self-administered structured questionnaire GHQ-12(12).

The type of cutoff point used for the questionnaire is the following: each item is considered to be present (1) or absent (0), according to the GHQ method. The scale used will be 0011 (binary dichotomous variable), that is, the answers marked in the first two options of the question are considered negative (absent), while those that have the last two options as an answer are considered positive (present). Those who tested positive for three or more GHQ items (out of 12 items) will be classified as cases of minor psychiatric morbidity(13). The reference period for the GHQ was the two weeks prior to completing the questionnaire.

The research project was submitted to the Research Ethics Committee of the Pedro Ernesto University Hospital of the State University of Rio de Janeiro (HUPE/UERJ) for approval. Subsequently, the fieldwork was initiated, which consisted of the researcher applying the self-administered GHQ-12 questionnaire after the adolescents over 18 years of age or their guardians signed the consent form.

A test/retest reliability study was conducted for the GHQ-12 with patients admitted to the adolescent ward of the same hospital. Since it was impossible to administer the questionnaire to outpatients, this unit was chosen, since patients there generally remain hospitalized for a period longer than that necessary for reapplication of the questionnaire (three days). Demographic data were also collected from the patients’ medical records.

Reliability was assessed using the kappa coefficient , which measures levels of agreement between the responses provided by the adolescents on the two occasions, correcting for the agreement expected by chance(11). Thirty adolescents participated in this stage, with not very similar proportions of male (43.3%) and female (56.7%) patients. The average age of the interviewees was 15.8 years. These individuals were not included in the final analysis. The reliability found was almost perfect (κ = 0.84; 95% confidence interval [CI] 0.48-1).

DATA ANALYSIS

The EPI-INFO version 6.0 program was used to input the data from the questionnaire, and the STATA version 6.0 program was used to analyze the data.

After the general description of the data through simple and relative frequencies, the prevalence of CMD by sex was calculated according to the sociodemographic variables age, family income and education.

Subsequently, the crude and adjusted odds ratios (OR) and the respective 95% CI of the explanatory variables were calculated. The presence of CMD was defined as a dependent variable and was considered binary data, that is, 0 or 1 for absence or presence of CMD.

Multivariate analysis was then performed to assess the role of sociodemographic variables as potential confounders in the association of explanatory variables related to chronic disease and the presence of CMD. The age variable was divided into three categories (12 to 14, 15 to 17 and 18 to 20 years) to facilitate the analysis, gathering a larger number of individuals in each stratum. Regarding education, those who were attending high school and had completed elementary school (1st to 8th grade) and those who, because they were attending university, had already completed high school (1st to 3rd grade) were grouped into the same stratum. Family income was concentrated in two strata: less than three minimum wages and greater than or equal to three minimum wages, which allowed for a more homogeneous distribution of individuals. The main chronic disease was analyzed taking into account the tenth revision of the International Classification of Diseases (ICD-10); pathologies in which there were few individuals in the stratum were classified as other.. The time of evolution of the main chronic disease was categorized as follows: less than three months, greater than or equal to three months and less than six months, greater than or equal to six months and less than one year and greater than or equal to one year. The other variables, such as presence of associated chronic disease and presence of associated non-chronic disease, were analyzed as binary variables (yes or no).

RESULTS

The study population consisted of 207 adolescents, 113 (54.59%) males and 94 (45.41%) females. Ages ranged from 12 to 20 years, inclusive. Forty-four individuals (21.26%) were between 12 and 14 years old, 98 (47.34%) were between 15 and 17 years old and 65 adolescents (31.40%) were between 18 and 20 years old. Most individuals had incomplete primary education (108 adolescents, or 52.17%); only one (0.48%) had never attended school; 77 adolescents (37.2%) had completed primary education but incomplete secondary education, and 21 (10.14%) had completed secondary education and were attending university; no patient had completed university education. There were 96 individuals (46.37%) who had a family income less than or equal to three minimum wages, and 11 (53.62%) who reported having an income greater than three minimum wages.

Nineteen patients (9.17%) had been ill for more than three months and less than six months, 17 adolescents (82.21%) reported having had the main chronic disease for more than six months and less than one year, and the vast majority, 171 patients (82.61%), had been ill for more than one year.

Regarding the type of chronic disease, those originating from the circulatory system, according to ICD-10, represented 16.91% of the sample (35 patients); those originating from the musculoskeletal system and connective tissue, in a total of 102 patients, represented 49.27%; 46 patients (22.22%) presented pathologies of the genitourinary system; diseases that gathered few individuals in the stratum, such as congenital, skin and subcutaneous tissue and metabolic, were grouped into others and represented 11.6% of the sample (24 patients).

Sixty-four adolescents (30.92%) had some chronic pathology associated with the main disease; regarding the presence of another associated non-chronic disease, only eight individuals (3.86%) reported having it, and 199 patients (96.14%) did not have any other non-chronic pathologies associated with the main disease.

The overall prevalence of CMD in the study population was 44.9%. When we evaluated the prevalence of CMD according to the sample characteristics, we observed that the prevalence of CMD was higher among male patients (51.32%) than among female patients (37.23%), with this difference being statistically significant (CI 0.06-0.27, p=0.042). Regarding the other sociodemographic variables (age, family income and education), the differences between the prevalences did not show statistical significance.

In the results of the univariate analysis, stratifying by sex, the OR values ​​and respective 95% CI were observed. For the time of evolution of the underlying chronic disease greater than or equal to six months, we had an OR of 3.86% (95% CI 0.9-16.57) among male adolescents and 7.41% (95% CI 0.88-62.36) for females. Regarding the type of underlying chronic disease, we had an OR of 2.55 (95% CI 0.96-6.77) for diseases originating in the circulatory system and 1.91 (95% CI 0.65-5.58) for those originating in the genitourinary system, in female patients. The presence of chronic disease associated with the underlying disease revealed an OR of 1.53 (95% CI 0.62-3.8) in girls. The presence of associated non-chronic disease revealed, in male adolescents, an OR of 5.09 (95% CI 0.57-45.07). It was not possible to perform the analysis for females, since all girls with non-chronic disease associated with the main chronic disease had CMD. The values ​​described did not show statistical significance at the 5% level. The association between the fact that the underlying chronic disease originated in the circulatory system and the presence of CMD in girls was only marginally significant (95% CI 0.96-6.77).

For the final model, the variables that presented OR values ​​greater than 1 were selected, i.e., presence of associated non-chronic pathology, presence of associated chronic pathology, time of disease evolution, diseases of the circulatory system and pathologies of the genitourinary system. Of the sociodemographic variables, only sex was significantly associated with the presence of CMD; therefore, the other variables were not included in the final model.

When adjusting for all explanatory variables and stratifying by sex, we noted that diseases originating from the genitourinary system in male patients showed a change in OR (0.42; 95% CI 0.16-1.22 to 1.46; 95% CI 0.46-4.6), although this was not statistically significant. The other variables in the model did not show significant changes.

In female patients, diseases of the genitourinary system that presented OR = 1.91 (95% CI 0.65-5.58) in the univariate analysis had an adjusted OR of 0.69 (95% CI 0.22-2.13). We previously observed that the opposite occurred with boys. The time of disease progression between six months and one year also showed changes in OR values ​​from 3.86 (95% CI 0.9-16.57) to 1.82 (95% CI 0.25-13.24). The other variables in the model did not show major changes after adjustment. We observed that in this stratum, the values ​​obtained were not statistically significant either.

DISCUSSION

As expected, the overall prevalence of CMD found in this study (44.9%) was higher than that reported by other researchers in samples of adolescents (between 12.6% and 35%)(23,25) and in the general population (between 7% and 26%)(9). According to Coupey(7), health professionals who deal with adolescents with chronic diseases should be attentive to the mental health of their patients. In this study, we can see that such an attitude is indeed desirable given the high prevalence found.

In the literature, only two studies were found that evaluated the prevalence of CMD among adolescents(23,25). Likewise, in the study conducted by Peltzer(25), the sample consisted of adolescent schoolchildren from South Africa who did not suffer from any type of disease. Newacheck(23) observed that chronically ill adolescents have a 35% higher risk of developing behavioral disorders that include anxiety and depression, but also other factors, such as hyperactivity, antisocial behavior, family conflicts and school failure. The studies found deal much more with behavioral and social problems than with minor psychiatric morbidity per se.

Peltzer(25) also mentions financial situation as a factor associated with the presence of CMD in adolescents. In our study, when we observed the sociodemographic characteristics of the study population, we found that adolescents with a family income of less than three minimum wages presented a higher prevalence of CMD than those with a family income greater than this value. Patients with a lower level of education were those who showed a higher prevalence of CMD. The prevalence values, when we observed the level of education, were inversely proportional to the number of years of study of the adolescent. These findings agree with those obtained by Gortmaker et al. (1990) when they mention that family income is associated with the risk of developing behavioral problems among adolescents.

Some studies suggest differences in the propensity to develop mental disorders between genders. Suris et al.(28) concluded that female adolescents, when chronically ill, were more likely to develop mental disorders than male adolescents. On the other hand, Pless et al.(26) and Gortmaker et al.(15) presented opposite results when they demonstrated that male individuals had a higher risk of developing emotional disorders. In our study, we also observed that CMDs were more prevalent in chronically ill male adolescents; this difference was statistically significant. No studies were found in the literature that evaluated the association of CMDs with the different age groups of adolescence; in our population, we observed that the prevalence of CMDs did not show considerable variations between the different age groups, although the results found were not statistically significant.

Orr et al. (24) observed, in a case-control study, adolescents who had a chronic disease lasting more than three months, compared them with controls without diseases, and concluded that the former were more vulnerable to some type of psychosocial dysfunction without, however, considering that the presence of a chronic disease was capable of producing important psychiatric disorders. Also in our study, all adolescents interviewed had been ill for more than three months, but when we performed the univariate analysis, we observed that the association with the CMD outcome for those who had been ill for more than six months and less than one year, both males (OR=7.41; 95% CI 0.88-62.36) and females (OR=3.86; 95% CI 0.9-16.57), did not reveal statistical significance, although it showed OR values ​​greater than 1. These results were maintained when the multivariate analysis was adjusted for all other variables in the model and stratified by sex. In patients who had been ill for more than a year, no association with CMD was observed, which could be explained by a possible adaptation to the fact of being ill, perhaps greater trust in their attending physician, or both. However, we did not find any studies in the literature that corroborate these findings.

Some studies relate a greater propensity to develop psychological disorders with the presence of physical limitations imposed by the disease(3,29). The number of patients who presented physical limitations in our study was very small and was not included in the analysis, since the patients who are treated at the Center for Studies on Adolescent Health (NESA) often come from distant places, and those who have this type of limitation end up seeking treatment in places closer to their homes. On the other hand, when we evaluated the type of main chronic disease, we noticed that those originating in the circulatory system (including severe heart disease) showed, in girls, a marginally significant association with CMD when we performed the univariate analysis (OR=2.55; 95% CI 0.96-6.77). We could think of severe heart disease as a form of physical limitation, since in these cases the patients are often unable to perform their daily physical activities without having some type of symptom such as dyspnea, palpitations or chest pain; Many girls included in this group had already undergone surgery to place valve prostheses and, therefore, had extensive scars on their chests, which could be a factor that generates anxiety and/or depression, since their body image was seriously affected.

Newacheck et al. (23) observed that the impact of the presence of multiple pathologies on the generation of psychological disorders is much greater when compared to situations in which only one chronic disease occurs. When we observed the crude and adjusted ORs of the association between the presence of more than one chronic disease and the outcome, we found values ​​greater than 1; in girls, however, there was no statistical significance in this association.

The main limitation of this study is the impossibility of inferring the results for the general population of adolescents with chronic disease, since the population studied cannot be considered representative of the universe of chronically ill adolescents in the state of Rio de Janeiro and Brazil. However, we can infer the results for the population of Brazilian adolescents who use public health services located in university hospitals.

Some considerations regarding the methodology are pertinent: the fact that the NESA outpatient clinic has a fixed team of professionals who treat adolescents with chronic diseases minimizes the possibility of classification bias. Information about the time of evolution of the main chronic disease was obtained through consultation carried out by the researcher herself in the patients’ medical records, which aimed to avoid information bias that could occur if the patients themselves provided such information. The methodological differences between the studies involving adolescents with chronic diseases made the comparison of results more difficult.

Regarding the type of main chronic disease, the stratification, which was performed based on ICD-10 coding, allowed for a better visualization of the sample, but caused a loss in the power to identify significant associations when the number of individuals in the different strata was considerably reduced.

The limitation imposed by sample size did not allow for the estimation of associations between the explanatory variables and the outcome with the desired precision, which points to the need for further studies with larger samples. However, it is possible to see that the factors studied had an influence on predicting the presence of the CMD outcome. It is really important to conduct further studies on the subject, since the prevalence of minor psychiatric morbidity found in this study far exceeded the data found in the world literature. Longitudinal studies that could evaluate the factors described as risk factors would be of great importance.