Among the most prevalent and disabling chronic diseases affecting reproductive-aged women worldwide, depression and anxiety can contribute to adverse reproductive health outcomes, including an increased risk of unintended pregnancy and its health and social consequences. For women with these common mental health conditions who want to avoid an unintended pregnancy, effective contraception can be an important strategy to maintain and even improve health and well-being. Reproductive health clinicians play a critical role in providing and managing contraception to help women with mental health considerations achieve their desired fertility. In this commentary, we review the literature on relationships between mental health and contraception and describe considerations for the clinical management of contraception among women with depression and anxiety. We discuss issues related to contraceptive method effectiveness and adherence concerns, mental health–specific contraceptive method safety and drug interaction considerations, and clinical counseling and management strategies. Given important gaps in current scientific knowledge of mental health and contraception, we highlight areas for future research.
Depressive and anxiety disorders are among the leading causes of disability in the United States and worldwide. Compared with men, US women are 70% more likely than men to experience a depressive disorder and 60% more likely to experience an anxiety disorder. Approximately 12% of women will experience major depression in their lifetime; 8.4% will experience a depressive disorder each year. Women experience anxiety disorders at even higher rates, and anxiety disorders are highly comorbid with depression. And although common, depression and anxiety disorders often go undetected and untreated among reproductive-aged women. In recent years, less than half of US women aged 15-44 years with a major depressive episode received a mental health diagnosis and less than half received treatment. Moreover, poor, unemployed, and less educated women experience higher rates of mental health disorders and lower rates of mental health detection and treatment than their socially advantaged counterparts; racial/ethnic minority women receive mental health care at even lower rates.
Mental health, unintended pregnancy, and reproductive outcomes
Women with depression and anxiety experience an elevated risk of unintended pregnancy, and those pregnancies may be more likely to end in induced abortion, compared with women without depression and anxiety. Depression and anxiety are precursors to a host of negative perinatal and postpartum outcomes, including maternal and infant morbidity, obstetrical complications, preterm labor, stillbirth, low birthweight, and antepartum and postpartum depression, especially when pregnancies are unintended. Poor, underinsured, undereducated, and minority women disproportionately suffer mental health morbidity, low rates of detection and treatment, and adverse reproductive outcomes, including unintended pregnancy.
Relationships between mental health and contraception
Effects of contraception on mental health
Deficiencies in neurotransmitters that have an impact on mood (serotonin, norepinephrine, dopamine, γ-aminobutyric acid, and peptides) have been implicated in clinical studies of depression and anxiety, and genetic predisposition and psychosocial stressors appear to be important precursors to neurotransmitter deficiencies. Contraceptive researchers in the 1960s and 1970s hypothesized that large dosages of synthetic estrogens and progestins in combined oral contraceptive pills (COCs) (eg, 5 mg norethynodrel, 75 μg mestranol) could potentially interact with mood-related neurotransmitters and neurotransmitter metabolism.
Although there have been no published clinical trials to date using hormonal bioassays or brain imaging to clarify these relationships, newer evidence suggests that the steroidal activity of lower-dosage modern contraceptives do not have a clinically relevant physiological impact on women’s mood or mood-related neuroendocrine functioning. In a systematic review of studies examining COC pharmacological properties and mood, Robinson et al found no evidence for an association between the intrinsic biochemical mechanisms of COCs and mood side effects reported by COC users.
In the 2010 Medical Eligibility Criteria for Contraceptive Use report, the Centers for Disease Control and Prevention (CDC) concluded there are no contraindications to hormonal contraception for women with depression, citing a lack of evidence supporting a causal relationship. Prospective population-based cohort studies and clinical placebo-controlled trials have consistently reported similar or even lower rates of depression or mood symptoms in COC users compared with nonusers. More recent pharmacological research on fourth-generation drospirenone-containing COCs found improvements of premenstrual dysphoric disorder (PMDD) mood symptoms. Research on the depot medroxyprogesterone acetate injectable (DMPA), transdermal patch, vaginal ring, subdermal implant, and levonorgestrel-releasing and copper-containing intrauterine devices (IUDs) has also found no evidence of negative mood effects with the use of these methods. Given that some recent studies have relied upon observational and cross-sectional designs and small sample sizes, additional research that uses rigorous prospective, longitudinal, and randomized controlled trial designs is needed to provide a more definitive comment on the null effects of contraception on women’s mental health.
Effects of mental health on contraceptive behavior
A growing number of studies have documented higher rates of contraceptive nonuse, misuse, and discontinuation among women with depressive, anxiety, and related stress and distress symptoms compared with women without symptoms. These findings, which have been consistent across studies, populations, and settings, have been most widely noted for COCs and condoms but have also been demonstrated for DMPA, IUDs, and implants.
The impact of mental health on contraceptive method selection is less clear. Some clinical and population-based studies of nonpregnant women have found less effective method use (ie, condoms and withdrawal vs COCs and long-acting reversible contraception) to be associated with higher depression and stress symptoms, whereas a study of postabortion patients found higher rates of IUD use was associated with greater mental distress symptoms. Reasons for these differences across contexts are not fully apparent and warrant further research.
Little science exists to explain how or why mental health influences contraceptive behavior. Psychological research suggests that altered cognitive processes may contribute to heightened perceptions of physical symptoms among women with mental health conditions. COC discontinuation rates from perceived mood symptoms are not uncommon (range, 14–21% in some studies), despite the evidence refuting causal associations.
Depressed or anxious women may also internalize negative or incorrect information about contraception and have exaggerated concerns about risks and side effects. Additionally, risk assessment, planning, social learning, decreased motivation, and desire for self-care, excessive worry, and diminished perceptions of susceptibility to pregnancy may have an impact on contraceptive decision-making processes and lead to suboptimal contraceptive choices among women with depression and anxiety. Additional studies are needed to test these mechanistic theories.
Relationships between mental health and contraception
Effects of contraception on mental health
Deficiencies in neurotransmitters that have an impact on mood (serotonin, norepinephrine, dopamine, γ-aminobutyric acid, and peptides) have been implicated in clinical studies of depression and anxiety, and genetic predisposition and psychosocial stressors appear to be important precursors to neurotransmitter deficiencies. Contraceptive researchers in the 1960s and 1970s hypothesized that large dosages of synthetic estrogens and progestins in combined oral contraceptive pills (COCs) (eg, 5 mg norethynodrel, 75 μg mestranol) could potentially interact with mood-related neurotransmitters and neurotransmitter metabolism.
Although there have been no published clinical trials to date using hormonal bioassays or brain imaging to clarify these relationships, newer evidence suggests that the steroidal activity of lower-dosage modern contraceptives do not have a clinically relevant physiological impact on women’s mood or mood-related neuroendocrine functioning. In a systematic review of studies examining COC pharmacological properties and mood, Robinson et al found no evidence for an association between the intrinsic biochemical mechanisms of COCs and mood side effects reported by COC users.
In the 2010 Medical Eligibility Criteria for Contraceptive Use report, the Centers for Disease Control and Prevention (CDC) concluded there are no contraindications to hormonal contraception for women with depression, citing a lack of evidence supporting a causal relationship. Prospective population-based cohort studies and clinical placebo-controlled trials have consistently reported similar or even lower rates of depression or mood symptoms in COC users compared with nonusers. More recent pharmacological research on fourth-generation drospirenone-containing COCs found improvements of premenstrual dysphoric disorder (PMDD) mood symptoms. Research on the depot medroxyprogesterone acetate injectable (DMPA), transdermal patch, vaginal ring, subdermal implant, and levonorgestrel-releasing and copper-containing intrauterine devices (IUDs) has also found no evidence of negative mood effects with the use of these methods. Given that some recent studies have relied upon observational and cross-sectional designs and small sample sizes, additional research that uses rigorous prospective, longitudinal, and randomized controlled trial designs is needed to provide a more definitive comment on the null effects of contraception on women’s mental health.
Effects of mental health on contraceptive behavior
A growing number of studies have documented higher rates of contraceptive nonuse, misuse, and discontinuation among women with depressive, anxiety, and related stress and distress symptoms compared with women without symptoms. These findings, which have been consistent across studies, populations, and settings, have been most widely noted for COCs and condoms but have also been demonstrated for DMPA, IUDs, and implants.
The impact of mental health on contraceptive method selection is less clear. Some clinical and population-based studies of nonpregnant women have found less effective method use (ie, condoms and withdrawal vs COCs and long-acting reversible contraception) to be associated with higher depression and stress symptoms, whereas a study of postabortion patients found higher rates of IUD use was associated with greater mental distress symptoms. Reasons for these differences across contexts are not fully apparent and warrant further research.
Little science exists to explain how or why mental health influences contraceptive behavior. Psychological research suggests that altered cognitive processes may contribute to heightened perceptions of physical symptoms among women with mental health conditions. COC discontinuation rates from perceived mood symptoms are not uncommon (range, 14–21% in some studies), despite the evidence refuting causal associations.
Depressed or anxious women may also internalize negative or incorrect information about contraception and have exaggerated concerns about risks and side effects. Additionally, risk assessment, planning, social learning, decreased motivation, and desire for self-care, excessive worry, and diminished perceptions of susceptibility to pregnancy may have an impact on contraceptive decision-making processes and lead to suboptimal contraceptive choices among women with depression and anxiety. Additional studies are needed to test these mechanistic theories.
Principles for clinical management of mental health and contraception
Mental health and the reproductive health encounter
Depression and anxiety may have important implications for family planning, and reproductive health settings offer an optimal opportunity to improve detection and treatment of these common mental health conditions among reproductive-aged women. Risk factors for mental health conditions should be identified in the past medical history, including personal or family history of depression and anxiety or other mental health disorders, other chronic medical illnesses such as cancer, stroke, or HIV/AIDs, and having adverse life experiences, including exposure to physical and sexual violence or trauma.
Signs and symptoms of depression and anxiety can have an impact on patient-provider communication and interaction in important ways but may not be obvious to the provider or patient. Lack of awareness and insight into mental health issues and perceived stigma are barriers to disclosure of mental health symptoms. Assessment of psychological well-being and its impact on sexual and reproductive health functioning should be a routine component of the patient interview. Patience, empathy, and use of reflective listening, a nonjudgmental tone, and open-ended questions may facilitate women’s comfort in disclosing mental health issues.
Discussions can be initiated with an educational statement such as, “Did you know that more than one fifth of women will have symptoms that meet criteria for depression in their lifetime? Because depression is so common, I like to check in with all my patients about their own mental health.” Observing for a sad voice, anxious expressions, lethargic posture, or a clinical presentation of multiple, vague complaints, nonspecific symptoms, or pain-related syndromes (eg, nonspecific vulva, pelvic, vaginal, coital, or menstrual-related pain, headaches, or gastrointestinal disturbances) may alert providers to an underlying depressive or anxiety disorder. Providers should also monitor for transference: feeling down, sad, and upset after seeing a distressed patient.
In busy clinical settings, standardized mental health screening is an efficient, effective, and feasible way to improve detection of depression and anxiety and thus should be used routinely and systematically, including with all well-woman examinations and new patients. Table 1 highlights commonly used, evidence-based screening instruments. The Prime-MD Patient Health Questionnaire (PHQ) is perhaps the most commonly used, preferred screening tool in current primary care and other nonpsychiatric settings and can be seamlessly included in electronic medical record charting. Standardized diagnostic criteria such as those delineated in the Diagnostic and Statistical Manuel of Mental Disorders should be followed when diagnosing a depressive or anxiety disorder.
| Instrument name | Items; scoring criteria | Example items |
|---|---|---|
| Prime-MD PHQ | 2- and 9-item versions depression subscale; 0, not at all to 3, nearly every day. |
|
| 5-item anxiety subscale, yes or no |
| |
| CES-D | 10- and 20-item versions; 0, rarely or none of the time to 3, most or all of the time |
|
| Beck Depression Inventory–Revised | 21 groups of statements; choose 1 of each group |
|
| DASS | 21- and 42-item versions; 0, not at all to 3, very much or most of the time |
|
| BAI | 21 items; 0, not at all to 3, severely—it bothered me a lot |
|
| Spielberger State and Trait Anxiety | 40 items; 0, almost never to 3, almost always |
|
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