EXECUTIVE SUMMARY

Depression is not uncommon among reproductive-age women. Data from a just-released analysis indicate that nearly 5% of American women of childbearing age have symptoms of major depression, with about 33% of women with severe symptoms reporting antidepressant use.

  • On a related note, results of a new review of all available data indicate no evidence to support a link between progestin-only birth control and depression.
  • There has been limited, conflicting data linking progestin-only contraception, such as the contraceptive shot (depot medroxyprogesterone acetate, DMPA) and the contraceptive implant, with increased risk for depression. While one study showed a slight increase in the likelihood of depression in DMPA users, other studies have shown no association.

Depression is not uncommon among reproductive-age women. Data from a just-released analysis indicate that nearly 5% of American women of childbearing age have symptoms of major depression, with about 33% of women with severe symptoms reporting antidepressant use.1 It is estimated that at any given time, one in 20 teens meets clinical criteria for a mood disorder and up to one in four children will experience a mood disorder by their late adolescence.2

There has been limited, conflicting data linking progestin-only contraception, such as the contraceptive shot (depot medroxyprogesterone acetate, DMPA) and the contraceptive implant, with increased risk for depression. While one study showed a slight increase in the likelihood of depression in DMPA users, other studies have shown no association.3,4 Good news: Results of a new review of all available data indicate no evidence to support a link between progestin-only birth control and depression.5

“Depression is a concern for a lot of women when they’re starting hormonal contraception, particularly when they’re using specific types that have progesterone,” notes Brett Worly, MD, lead author and assistant professor of obstetrics and gynecology at Ohio State University Wexner Medical Center. “Based on our findings, this side effect shouldn’t be a concern for most women, and they should feel comfortable knowing they’re making a safe choice.”

Review the Data

To conduct the analysis, researchers performed a systematic review of data tied to various progestin-containing contraception methods, including injections, implants, and pills. The analysis also included studies examining the effects of hormonal birth control on postpartum women, adolescents, and women with a history of depression. There is insufficient evidence to prove a link between progestin-only birth control and depression, researchers concluded.5

“This study is particularly important at this time when other studies with poor design6 or poor statistical interpretation7 have been highly publicized and raise the specter in the general population that hormonal contraception increases the risk of depression,” states Anita Nelson, MD, professor and chair of the obstetrics and gynecology department at Western University of Health Sciences in Pomona, CA.

The current review includes only studies with objective measures of depression, instead of complaints of sadness or mood changes, comments Nelson. Progestin is the presumed culprit, so it is particularly reassuring that this article focused directly on progestin-only methods and found no attributable increase in risk of developing depression, she states.

Talk With Patients

In counseling women on contra-ceptive choice, clinicians must keep in mind that the best method is one that will be in harmony with a patient’s wishes, fears, preferences, and lifestyle if it is to be used consistently and correctly.8

Providers also need to be mindful of the possibility of mood disorders among patients, and to be proactive regarding providing or facilitating treatment of depression when it is identified, says Andrew Kaunitz, MD, University of Florida term professor and associate chairman of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine-Jacksonville.

“Adolescents and pregnant moms will sometimes have a higher risk of depression, not necessarily because of the medicine they’re taking, but because they have that risk to start with,” said Worly in a press statement. “For those patients, it’s important that they have a good relationship with their healthcare provider so they can get the appropriate screening done — regardless of the medications they’re on.”

Remind patients that use of the progestin-only shot, implant, and progestin-only pill in women with depressive disorders all are rated as Category 1 (a condition for which there is no restriction for the use of the contraceptive method) in the US Medical Eligibility Criteria for Contraceptive Use.9 For women taking psychotropic medications such as selective serotonin reuptake inhibitors (SSRIs), there is no evidence specifically examining the use of progestin-only contraceptives with such drugs. Limited clinical and pharmacokinetic data do not indicate an effect of SSRIs decreasing the effectiveness of oral contraceptives.9

Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta, reminds readers that caution should be used in providing DMPA postpartum for a woman with a history of severe postpartum depression. Clinicians may consider waiting until six weeks postpartum for the first injection.8 

REFERENCES

  1. Guo N, Robakis T, Miller C, Butwick A. Prevalence of depression among women of reproductive age in the United States. Obstet Gynecol 2018 Mar 8; doi:10.1097/AOG.0000000000002535. [Epub ahead of print].
  2. Tang MH, Pinsky EG. Mood and affect disorders. Pediatr Rev 2015;36:52-60.
  3. Civic D, Scholes D, Ichikawa L, et al. Depressive symptoms in users and non-users of depot medroxyprogesterone acetate. Contraception 2000;61:385-390.
  4. Gupta N, O’Brien R, Jacobsen LJ, et al. Mood changes in adolescents using depot-medroxyprogesterone acetate for contraception: A prospective study. J Pediatr Adolesc Gynecol 2001;14:71-76.
  5. Worly BL, Gur TL, Schaffir J. The relationship between progestin hormonal contraception and depression: A systematic review. Contraception 2018; doi:10.1016/j.contraception.2018.01.010. [Epub ahead of print].
  6. Skovlund CW, Mørch LS, Kessing LV, Lidegaard O. Association of hormonal contraception with depression. JAMA Psychiatry 2016;73:1154-1162.
  7. Bengtsdotter H, Lundin C, Gemzell Danielsson K, et al. Ongoing or previous mental disorders predispose to adverse mood reporting during combined oral contraceptive use. Eur J Contracept Reprod Health Care 2018;23:45-51.
  8. Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
  9. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016;65:1-103.