Contraception for women with mental illness

Women with psychiatric disorders who use contraception may have comparable or lower rates of mood symptoms with hormonal contraceptives than those who use other types of contraception, or no contraception at all, according to a literature search in The American Journal of Psychiatry.¹

“Mental health care for women includes decision support to prepare for major life events, including preconception planning for treatment during pregnancy and the postpartum period,” wrote the authors.

A search of PsycINFO, PubMed, Embase, and Scopus revealed that the majority of women with psychiatric disorders choose combined oral contraceptives (COCs).

However, long-acting reversible contraceptives (LARCs), like subdermal implants and intrauterine devices (IUD,) were selected by only 14% of women despite low failure rates, impressive safety profiles, rapid return to fertility after removal, and few contraindications.

This relatively low rate of IUD is attributed to persistent concerns about pelvic infections linked to IUDs that are no longer available, fear of pain with placement, changes in menstrual bleeding, and perceived lack of control over IUD removal.

A protective effect of hormonal contraceptive for depression was demonstrated in a study of women aged 25 to 34.² Compared to sexually active women using either no contraception or nonhormonal contraception, combined hormonal contraception users had lower mean depressive symptom levels and were significantly less likely to report a past-year suicide attempt. Women using progestin-only contraceptives also had a protective association with depressive symptoms.

In contrast, a Danish population-based study found that adolescents, aged 15 to 19, who used a hormonal contraceptive were twice as likely to initiate antidepressant treatment.³ The relative risk for those who took progestin-only pill preparations was 2.2 compared to 1.8 for COCs. The risk period peaked at 6 months, then declined.

However, the National Comorbidity Survey–Adolescent Supplement study, which included adolescents who had never been pregnant, concluded there was no increased risk of depressive disorders among oral contraceptive pill (OCP) users.⁴ This is contrary to drug registry studies, but consistent with other studies using individual-level survey data and validated screening tools.

The authors of the study noted that young women who incur mood disturbances while using OCPs should consult physicians; however, there is insufficient evidence to be concerned about depressive disorders among adolescents who use birth control.

In fact, one of the most well-documented increased depression risks for women is pregnancy.

The authors of the review noted that all methods of contraception are acceptable for women with depression, but medical comorbidities may dictate a specific type.

In addition, interactions between psychotropic drugs and contraceptives are rare, with the exceptions of clozapine, anticonvulsants, and St. John's Wort.

“Proactive management of mental illness, contraception, and pregnancy improves a woman's capacity to function and optimizes her mental and reproductive health,” the authors concluded.

References:

1. McCloskey LR, Wisner KL, Cattan MK, et al. Contraception for women with psychiatric disorders. Am J Psychiatry. 2021 Mar 1;178(3):247-255. doi:10.1176/appi.ajp.2020.20020154
2. Keyes KM, Cheslack-Postava K, Westhoff C, et al. Association of hormonal contraceptive use with reduced levels of depressive symptoms: a national study of sexually active women in the United States. Am J Epidemiol. 2013; 178:1378–1388. doi:10.1093/aje/kwt188
3. Skovlund CW, Mørch LS, Kessing LV, et al. Association of hormonal contraception with depression. JAMA Psychiatry. 2016; 73:1154–1162. doi:10.1001/jamapsychiatry.2016.2387
4. McKetta S, Keyes KM. Oral contraceptive use and depression among adolescents. Ann Epidemiol. 2019; 29:46–51. doi:10.1016/j.annepidem.2018.10.002