Print version ISSN 0101-8108
Rev. psiquiatr. Rio Gd. Sul vol.30 no.3 Porto Alegre Sept./Dec. 2008
Infertility: association with common mental disorders and the role of social support*
Maria do Carmo Vieira da CunhaI; João Alberto CarvalhoII; Rivaldo Mendes AlbuquerqueIII; Ana Bernarda LudermirIV; Moacir NovaesV
IPsychiatrist. Master's Degree student
in Neuropsychiatry and Behavioral Science, Universidade Federal de Pernambuco
(UFPE), Recife, PE, Brazil.
IIAssociate professor I, UFPE.
IIIAssociate professor, Coordinator of the Graduate Program, Medical School, Universidade de Pernambuco (UPE), Recife, PE, Brazil.
IIAssociate professor IV, UFPE.
VAssociate professor, UPE.
INTRODUCTION: A diagnosis of infertility
may be devastating for a couple. Many infertile women perceive the situation
as stigmatizing, a cause of psychic distress and social isolation. This study
aimed at determining the economic, demographic, interpersonal, social and work
variables and also the prevalence of common mental disorders in a population
of women seen in reference hospitals for infertility (Hospital Agamenon Magalhães,
Amaury de Medeiros Integrated Health Center and Instituto Materno Infantil de
Pernambuco), and referred to the Mental Health in Human Reproduction Outpatient
Clinic at Hospital Universitário Oswaldo Cruz.
METHOD: This was a cross-sectional study conducted in 2007 with a total of 60 patients, who answered two self-reporting questionnaires: the Self-Reporting Questionnaire-20 (SRQ-20) and a questionnaire designed by the researcher.
RESULTS: Of the 60 women studied, 44% were aged 31 or older. The overall prevalence of common mental disorders was 53.3%. It was much more common in women aged 31 or older than in those aged 30 or less (66.7 vs. 37.0%). The patients who avoided social situations that could cause emotional discomfort presented a higher rate of common mental disorders.
CONCLUSIONS: The prevalence of common mental disorders and their association with social coping underlies the need for an interdisciplinary approach, including mental health professionals. Our data confirm the importance of social support and the inclusion of the male partner in the infertility evaluation process.
Keywords: Infertility, mental disorders, prevalence, social support, stigma.
Diagnosis and epidemiological aspects
The World Health Organization (WHO) acknowledges infertility is a disorder affecting men and women all over the world. According to the WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple,1 every year there are 2 million new cases of infertility, and approximately 8% of the couples have some problem related to infertility during their reproductive life. This is responsible for significant pressure in the financial resources of health systems.
The estimate of the international prevalence of infertility and the search for treatment showed that the frequency and the demand for medical services to treat infertility were lower than those previously mentioned and quite similar among developing and developed countries.2
Since prehistory, petroglyphs portrayed women representing fertility and prosperity. For several civilizations, women have symbolized fertility.3
Ancient people believed that the fertility of the soil and of all species is a single phenomenon, determined by divine will. The eternal fertility of the soil and of all species represented hope for ancient people. Infertility was symbolized by the image of death.4
Some Bible texts show blessing and fertility as synonyms, as well as curse and infertility. In these texts, adultery and incest are not considered crimes when their purpose is to repair infertility problems.5
The infertile woman is excluded from a cultural order that identifies femininity with motherhood and motherhood with biological reproduction. Therefore, infertility is not only a fault of nature, but it is also something that does not respect the established order, a fact that puts in doubt the truth of the femininity representations prevailing in the culture. The woman-mother is portrayed as different and opposed to the sexual woman; the sinner Eve can only be saved by Mary, the virgin-mother, who achieves motherhood without intervention of sexuality.5,6
Since only 5% of the married population voluntarily chooses not to have children, parenthood remains as an important goal for most men and women, being a necessary criterion to achieve personal satisfaction, social acceptance, religious affiliation, sexual identity and psychological adjustment. Therefore, fertility is a basic human function, and parenthood is a landmark in human development.7
A review of the literature about infertility and the psychological suffering related to it found that the impact of infertility on couples' psychological well-being has received increasing attention in the last few years. It seems evident that infertility is a deeply distressing experience for many couples.8 The authors of the study concluded that infertile patients have complex psychological difficulties with impact on several aspects of their sexual, affective, social and working lives.9-11
Although the psychological consequences of infertility are evident, it is not so clear how psychological disorders can affect fertility.
During the last few years, the study of the emotional aspects of infertility has gone through changes. For instance, within the general concept of psychogenic infertility, with a few exceptions, anxiety started to be considered a result and not the cause of infertility.12
Psychoanalytical authors believed that infertility in women was a consequence of the unconscious rejection of femininity and motherhood. They also thought it was related to issues linked to sexuality conflicts. However, less than 5% of the infertile couples have a physical cause for infertility, and this number is being reduced as medical knowledge evolved. The relationship between psychic states and physiological functions is highly complex, and there is not a simple and linear causal relation.13 It is also important to consider the conflicts present in couples that conceive naturally, since maybe similar conflicts can be found. We must be careful in order to avoid confounding causality with facts that can simply be related.14
Medicine offers the possibility of almost complete control over conception, as a consequence, having a child usually does not get anyone by surprise anymore. To have a child means to make a conscious wish come true based on a decision made with responsibility. If conception takes longer to happen, failure becomes unbearable, and these patients require fast results from the doctors in order to revive the refractory body.14
New reproduction technologies are transforming the concepts of infertility, mainly with regards to the knowledge about psychogenic infertility.15-19
Currently, the psychoanalytical literature has been trying to understand the meaning of infertility instead of looking for its cause. It assumes that we will be stepping on a more stable ground while analyzing the consequences of infertility instead of its causes. Even the psychoanalysts that analyze the prevalence of psychogenic infertility agree that the intense stress of infertility can promote regressions to earlier stages of the psychic development. Infertility can evoke powerful and frightening fantasies, affecting the whole personality.20
Psychological conflicts involving infertility reach the deepest layers of psychism, invade the couples' interpersonal and sexual space and spread to the sociocultural and working life and to the definition of family. Old conflicts are often revived, and they can be a threat for marital integrity. The couple's suffering can become worse due to invasive procedures and because of ethical and religious dilemmas created by recent technological opportunities.20
To deal with infertility is the same as dealing with severe clinical diseases. The despair of dealing with infertility is similar to the despair of dealing with devastating events such as the loss of a partner.21
The diagnosis of infertility usually is a threatening surprise. Even though the capacity to generate a child is postponed to adulthood, we relate to it in an early stage. Some children games are a rehearsal for the future performance of parenthood. One of the first enigmas that occupy children's mind is the one related to the origin of babies, as well as the maternal and paternal functions associated with these issues.22,23
The loss of the reproductive capacity greatly affects the narcissistic economy, especially because it is an important reference of identity for femininity and masculinity.20
For all human beings, the inability to have a child is deeply experienced as a narcissistic wound, but, within certain societies, one gender or the other is more protected.24
Four percent of the couples are not able to have children and they often lack social support. For some authors, after a period of many years, during which couples keep believing they will conceive, they will have to face the fact that having a child will not be possible. Therefore, they experience loss and grief. Even though they do not have to deal with real death, infertile people will go through a mourning process for a child that is not a possibility anymore.25
During treatment, infertile people feel they need support to go on with the treatment, hoping they will achieve success and not giving up.26
The perception of the stigma related to infertility and the pattern of revealing it to society can have an impact in the level of physical, emotional and social well-being, but these factors have not received enough attention.9
Women report they have to deal with a greater stigma related to infertility than men and they also provide more information about their difficulties with infertility. There are also differences between genders regarding the perception of the availability of social support. Women report depression, anxiety and suffering significantly more often than men.9,27,28
In face of the almost universal desire of having children, it would be expected that most people sought medical advice when they have difficulties to conceive. However, less than 55% of those who have infertility problems seek medical advice. The negative responses can significantly prevent 20% of women from seeking help, and the most important consequence of this fact is that education is absolutely necessary to avoid delay in the search for help.2
Psychosocial interventions in infertility demonstrate positive effects. Negative effects have not been found to affect the well-being of infertile people undergoing treatment. Feelings of anxiety, tension and concern almost always have shown some improvement.28
All these issues have an impact on the lives
of those involved and on the treatment, and they need to be approached from
a broad point of view, with the subjective issues also being taken into consideration
The analyses of these studies led us to try to understand the experience of infertility. The objective of the present study was to identify the presence of common mental disorders (CMD) and changes in the social life of those women referred to the Mental Health in Human Reproduction Outpatient Clinic of Hospital Universitário Oswaldo Cruz (HUOC) of Recife (PE).
The study was conducted at the Mental Health in Human Reproduction Outpatient Clinic of HUOC, a teaching hospital of Universidade de Pernambuco (UPE), which offers outpatient services in several specialties, including psychiatry and psychology.
This is a descriptive case series report. This design allowed for the detailed analysis of the cases, showing the frequencies of the variables, and making it possible to determine the prevalence of CMD in the infertile patients who were followed in the reference outpatient clinics, associating them with socioeconomic, demographic, working factors, as well as aspects related to social life and sexual relations. This is a exploratory quantitative approach, although many characteristics can be assessed in a qualitative manner.
Patients and sample
This study involved patients treated through the Public Health System (SUS), who were referred from three public outpatient clinics specialized in infertility in the city of Recife: outpatient clinic of Hospital Agamenon Magalhães (HAM), linked to the State Health Department; Centro Integrado de Saúde Amaury de Medeiros (CISAM), linked to Universidade de Pernambuco; and Instituto Materno Infantil Professor Fernando Figueira (IMIP). After previous contact, forms were sent to the physicians working at these outpatient clinics so that they could refer the patients to the Mental Health in Human Reproduction Outpatient Clinic of HUOC. The exclusion criteria were: (previous or current) disorders and psychiatric or psychological treatment, absence of a stable relationship and biological child from the current relationship.
The Self-Reporting Questionnaire-20 (SRQ-20) is an easy to administer self-report questionnaire and it can be used to help professionals to identify more recent psychiatric disorders in primary health care outpatient clinics. It was developed by the WHO with the purpose of detecting psychiatric problems in primary health care services in developing countries.29 Mari & Williams30 carried out a study in primary health care outpatient clinics in the city of São Paulo in order to validate this instrument in Brazil, and they demonstrated sensitivity of 85% and specificity of 80%. The SRQ-20 contains 20 yes/no questions. Four of them are about physical symptoms and 16 are related to psychoemotional disorders. According to these studies, the patients were divided in two groups depending on their score on the SRQ-20: non-suspected CMD & equal or lower than 7; suspected CMD & equal or higher than 8.
We also administered a semi-structured questionnaire developed by the main researcher for this study. The questionnaire included identification data, socioeconomic and demographic variables, and 41 questions about personal characteristics, such as: duration of the current relationship, other relationships, children from the current relationship or from other relationships, adopted children, duration of sexual relationship without contraceptives, number and duration of treatment, diagnosis of infertility, feelings after receiving the diagnosis and most stressful moment in the beginning of the medical treatment.
Statistical analysis and ethical aspects
For the analysis of data, we obtained absolute and percentage, univariate and bivariate distributions (descriptive statistical techniques), and we used Pearson's chi-square test with odds ratio (OR) values and respective confidence intervals (inferential statistical technique).
Data were entered in a Excel spreadsheet, and the data analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 13. The statistical tests considered an error margin of 5% and the confidence intervals were set at 95% (95%CI).
The research project and the text of the written consent form used in this study were approved by the Research and Teaching Ethics Committee of HUOC of UPE, in compliance with Resolution 196/96 of the Ministry of Health. The patients were informed about the confidentiality of the information. The Helsinki recommendations (World Medical Association, 1989)31 were respected.
Of the 66 women referred between January and December 2007, 60 met the inclusion criteria and filled out the SRQ-20 and the semi-structured questionnaire, which means we had a loss of 10%. Among those women included in the study, 53.3% had a CMD.
Table 1 show the distribution according to the sociodemographic variables. It is important to notice that: 45% of the patients were 30 years old or younger (n = 27) and 55% (n = 33) were 31 years old or older, with a mean age of 31.4.
In terms of educational level, 51.7% had completed elementary school (n = 31), and 48.3% (n = 29) had completed high school or college; 53.3% were married (n = 32) and 46.7% (n = 28) were single.
With regards to the duration of the marital relationship, 45% had lasted for 5 years (n = 27), 31.7% had lasted for 6 to 9 years (n = 19), and 23.3% had lasted for 10 years or longer (n = 14).
Most women from the sample (31.7%) had income lower than one minimum salary (n = 37), and 38.7% (n = 23) had an income of two minimum salaries. The couple's income was up to two minimum salaries for 58.6% of the women (n = 34), and for 39.7% (n=23) the income was from three to five minimum salaries.
Among the women included in this study, 58.3% (n = 38) of the partners had not married before. Among the women, 76.7% did not have children (n = 46) and most partners (66.7%) also did not have children; none of the women had children from the current marriage (exclusion criterion). Only 8.3% (n = 5) had adopted children from the current marriage. When asked about who had the strongest desire of having children, 61.7% (n =37) of the women answered that both had the same desire (patient and partner), and 26.7% (n = 16) answered that the patients were more willing to have children, while only 11.7% answered that the partner was more interested (n = 7). None of the women and none of the current partners had adopted children from other marriages.
We found that 88.3% perceived their difficulty to get pregnant (n = 53), and 78.3% (n = 47) felt "normal" before realizing they had difficulties to get pregnant; 60% (n = 36) believed that the difficulty to get pregnant was due to some specific fact or reason; 56.7% informed that they had been trying to get pregnant for more than 3 years without using any contraceptive methods; 65% reported they had been undergoing treatment for up to 1 year; 46.7% had not been treated before; 33.3% had been treated before; and 15% had gone through two treatments.
Three quarters of the women did not have a diagnosis of infertility, and, among the 15 women that had received the diagnosis, six reported to be feeling "sad". The adjective "horrible" was used to describe the feeling by three women. The most stressful moment was "during exams" for 81% of the women interviewed. Most of the women who participated in this study (68.3%) informed having changes in the feelings regarding themselves after they realized they were infertile.
Regarding social aspects, 56.7% of the women noticed some kind of change in their relationships with other people; 45% reported they stop going to certain places due to the fear of being asked about the fact that they still did not have children; 40% avoided places where they could meet pregnant women and children; 61.7% felt that people had doubts about their marriage because they still did not have children.
The variable age group showed significant association with CMD (p < 0.05; OR = 3.40; 95%CI), since CMD prevalence was quite higher among those patients who were 31 years old or older than among those who were 30 years old or younger (66.7 versus 37%) (Table 2).
The variable "change of feeling regarding themselves" also showed significant association at the significance level set in this study (p < 0.05; OR = 5.40), since the occurrence of CMD was quite higher among the patients who had changed the feelings regarding themselves in comparison to those who did not change their feelings (65.9 versus 26.3%). We found that, of the 49 women who stated that "during exams" was the most stressful moment, CMD were present in 27 (55.1%).
In terms of social relationships, the prevalence of CMD was higher among the patients who reported that there had been changes in the relationship with other people in comparison to those that denied any changes (73.5 versus 26.9%). We also found a higher prevalence of CMD: among those who did not avoid going to places where they could be asked about the reason for not having children than among those who avoided these places (74.1 versus 36.4%); among the women that reported they felt other people wondered why they did not have children than among those who did not feel it (67.4 versus 30.4%). These differences reveal a significant association of each one of the variables with the prevalence of CMD (p < 0.05) (Table 3).
This study was intended to investigate the hypothesis that women presented higher prevalence of CMD and had to deal with a deeper psychosocial impact in comparison to the general population during the period of evaluation for the diagnosis and treatment of infertility.
We found that the prevalence of CMD was 53.3% in our sample. The results suggest that the psychic conditions that women experience when they have to face infertility and during their search for a solution for the problem in outpatient clinics of infertility can worsen the prevalence of CMD. Our data are in accordance with several studies that have demonstrated the presence of symptoms that range from emotional pain to psychiatric disorders in these patients. This suggests that infertility must be seen as a process, instead of a series of independent emotional events, and that the suffering experienced by women due to infertility is a necessary part of the evolution to accept this condition. Our data also showed that it is necessary to pay more attention to the psychological aspects of women who are being seen in outpatient clinics of infertility.28,32,33
CMD have different prevalence rates around the world.34,35 Fortes et al.34 found prevalence of 56% of CMD. This finding is in agreement with our data, however, it is higher than the prevalence found by Ludemir & Melo Filho.35
Fortes et al.34 identified patients with comorbidities such as depression, anxiety, posttraumatic stress disorder, somatoform disorder and dissociative disorders, while, in our sample, the presence of these comorbidities was an exclusion criterion.
The larger number of patients with CMD in our sample was found among the patients with higher educational level, differently from what Ludemir & Melo Filho found in the general population.35 These authors detected lower educational levels among the subjects with CMD. Fortes et al.34 also found lower educational levels among the patients with CMD. It is possible to wonder if this difference, that is, higher educational level related to CMD found in our patients, is caused by the higher perception of the stigma of infertility, as well as because of the deeper knowledge they have about the technological advances they cannot use because of their financial limitations. And, in fact, in our study, we found that the social support is very important to reduce the stigma and, as a consequence, to lessen the negative feelings caused by the diagnosis of infertility.
These findings became evident when we detected that the prevalence of CMD was higher: among the patients who reported changes in the social relationship than among those that denied these changes (73.5 versus 26.9%); among those who informed they avoided certain places so that they would not be asked about the reason for not having children than among those who did not avoid these places (74.1 versus 36.4%); among those who reported avoiding places where there are pregnant women and children than among those who did not avoid these places (79.2 versus 36.1%); among those who informed feeling other people's doubts due to the fact they do not have children than among those who did not feel this problem (67.4 versus 30.4). These differences also revealed significant association for each one of these variables of the social relationship with the prevalence of CMD (p < 0.05). We can assume then that the difficulty to socially recognize and experience infertility could promote the occurrence of CMD.
The importance of social support in the context of stressors regarding infertility is well documented.9,36 In order to evidence the importance of this support, we can use the definition of social support provided by Minkler37 as being "any information, spoken or not, and/or financial help, offered by groups and/or people, with whom the patients would have systematic contact, resulting in positive emotional effects and/or behaviors. It is a reciprocal process, that is, it generates positive effects both for the subject that receives support and for those that offer support, allowing for both to have more meaning of control over their lives. From this process one can assume that people need each other" (free translation based on the Portuguese version of the text).
Sociofamilial network can work either as a factor of emotional overload or as an element that reduces suffering. The social support and its perception by the patient are associated with better global quality of life, both for men and women, being able to relieve emotional suffering. Psychological, educational and social interventions improve the well-being and the lives of people with infertility problems.
While assessing the variable "change of feelings regarding themselves", we found a significant association with the occurrence of CMD. Our findings are in agreement with the conclusions of Slade et al.,9 who believed that infertility can thread self-esteem due to its potentially stigmatizing nature. These authors consider that the stigma is generated from the shame of not meeting social expectations regarding motherhood. This condition would create a concentration hindering feelings and personal investments that could be aimed at its resolution.20 The results of our study are different from those by Downey et al.38 These authors found that infertile patients did not have lower self-esteem than controls, even though a large proportion of them, including those in the beginning of the treatment, reported symptoms of emotional suffering, using terms such as anxiety and depression to define their emotions and expressing fear regarding the uncertainty of their future, feeling afraid of medical interventions and concerned about their ability to have children. Other studies also revealed low self-esteem.39-41
Women who participated in our study mentioned the use of derogatory adjectives to describe them: "they call me banana-tree from hell"; "they say I'm hollow and dry"; "they say I'm a tree without fruits". Other women mentioned their identity and associated motherhood with femininity: "now they say I'm a man, they say: "there goes the male-woman". Based on this reports, we realized how infertility can be a stigmatizing experience. It can thread self-esteem and isolate the patient from sources of support.9 Stigma, prejudice and discrimination are social constructs that are highly related. It is the consequence of a social dynamics that can result in specific manifestations that are different in different cultures and, within the same culture, it may vary from one historical moment to another.41
Patients depreciate themselves, feel "sad" and "horrible" after realizing the difficulty of getting pregnant and feel socially depreciated, as if the only role they should play in their lives were being a mother. Some of them even report they are afraid of being left by their partners: "he said that if I don't get pregnant, he will leave me for another woman; I told him he can leave me since I can't get pregnant; then this anxiety that never stops can come to an end." They also reported feeling "guilty" for not having children, thinking that it might be "God's punishment". They keep asking themselves what they have done "wrong" and "why bad people have children, give their children away, abandon them, and they who want children so much cannot have them". The relations women establish between motherhood and femininity and the difficulties they face in the social relationships can explain our results regarding CMD.
While studying the social representations of motherhood and fatherhood, Trindade36 found that the sources of support most often mentioned by women were religion, family, friends and professionals. The author demonstrated that women usually take responsibility for infertility due to the social representation of motherhood as female identity, as if "being a mother were a basic condition to be woman", of motherhood as a "divine gift" and of overvaluation of the role of mother. Data obtained by this author, similarly to ours, reinforce the importance of social support, because these representations can make it difficult to get diversified support, which is necessary to regain emotional balance. These findings allow us to assume that social support is an important element of the balance of the emotional response when dealing with suffering caused by infertility.
We found that 68.8% of the patients belonging to the age group older than 30 years old (n = 22) had CMD. These data are not in agreement with those found by Serge-Jacob et al.,12 according to which older women had lower general suffering. We found that older women suffer a much higher pressure due to their age and because they might have a child with problems or "with a defect".
Even though a child is desired by most couples, not all of them seek medical help for their infertility problems, what makes it difficult to determine the accurate prevalence of the number of couples having this problem. Patients who do not seek professional help usually made unsuccessful attempts to have a child for almost 2 years, they are very pessimistic about their chances of having a natural pregnancy and, even so, they never saw a physician about their failure to conceive. Paradoxically, they do not want professional help not due to the invasive and technological nature of the medical intervention, but because of the thread associated with the confirmation of the infertility problem.2 In our study, we found that 81.7% of the patients informed that the most stressful moment was while they were doing the exams, which confirms our assumption. Among these patients, 55.1% had CMD.
In a study involving women 20 years after the investigation and the infertility treatment, 58% of the patients did not reply to the letters. Since, obviously, one cannot analyze the non-respondents, the authors just made the assumption of sensitivity regarding the topic infertility, even after 20 years. They assumed that the fear regarding the definition of the diagnosis is an obstacle that prevents patients from seeking medical services, and it also makes it more difficult for them to go to the mental health outpatient clinic, where they would have to talk about the difficulties of getting pregnant and their feelings regarding that issue. This is a subject that many patients want to hide because it represents emotional pain and stigma.41
Couples are expected not only to have children, but also they must "want" to have children. Some women are reluctant to talk about infertility even with their husbands, and many of them have this difficulty as a stigma for their whole lives.41 The stigma would not be associated with a physical deformity, but with a feeling of being different from the group's pattern. The assessment of the patients' perception with regards to this topic can help to identify those who are at higher risk of suffering, and the perception of the availability of social support can be associated with lower levels of suffering.9
The difficulty of inclusion of the patients in the specialized services is always present. Patients report that their husbands do not take part in the evaluations and that, when necessary, they have to take the requests for exams to their husbands and the results back to the physician. When the results of the exams are normal, they usually listen to comments such as: "your husband can get any woman pregnant." Due to these difficulties, similarly to most researchers, we only included women in the sample.
Although the results of this study are limited by the size of the sample and by the study design, with the use of only one instrument of psychological evaluation, in addition to the semi-structured questionnaire, we found that there is significant mental suffering and difficulties in the social relationship, which is the reason for additional longitudinal studies including men. Thus, it would be possible to identify the couple's suffering in several stages of the evaluation and treatment of infertility. Psychological knowledge can bring a contribution to the professionals who work with infertility so that they can better understand the psychic pain experienced by infertile people and, therefore, be better prepared to help them. The reduced number of subject in our sample can be related to the difficulties of professionals and patients to face the psychological issues related to infertility.
It would be useful if the reference services promoted educational campaigns for the general population with the purpose of reducing the stigma.
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Correspondence: Received August 16, 2008. There are no conflicts of interest associated
with the publication of this manuscript.
Maria do Carmo Vieira da Cunha
Rua João Ramos, 50/103
CEP 52011-090, Recife, PE, Brazil
Tel.: +55 (81) 3231.0368, +55 (81) 9961.7257
Accepted September 5, 2008.
Written consent form and study protocol approved by the Research Ethics Committee of Hospital Universitário Oswaldo Cruz of UPE (report CEP/HUOC no. 152/2006).
Study based on the master's degree thesis entitled "Infertility: consequences in the psychism and in the life of women during diagnosis and treatment", presented and approved in August 22, 2008 in the Graduate Program in Neuropsychiatry and Behavior Science of Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.
*This study was conducted at the Mental Health in Human Reproduction of Hospital Universitário Oswaldo Cruz, Universidade de Pernambuco (UPE), Recife, PE, Brazil.
Received August 16, 2008.
There are no conflicts of interest associated
with the publication of this manuscript.