How does contraception affect mental health in individuals with a history of depression or anxiety?

Contraception and Mental Health: Clinical Guidance for Patients with Depression or Anxiety History

For individuals with a history of depression or anxiety, hormonal contraception demonstrates protective effects against worsening depressive symptoms, though careful method selection and monitoring remain essential, as certain formulations may increase depression risk in vulnerable populations. 1

Key Clinical Considerations by Mental Health History

Patients WITH Pre-existing Depression or Anxiety

• Hormonal contraceptives show protective effects in women with established mental health disorders, with both randomized trials and cohort studies demonstrating slight protective effects against depression development (SMD -0.15 to -0.26). 1

• Anxiety symptoms specifically improve with hormonal contraceptive use in this population (SMD -0.20). 1

• Progestin-only contraceptives (POPs, DMPA, implants) do not worsen depression in women with pre-existing depressive disorders, with evidence showing no increase in depressive symptoms compared to baseline. 2

• Current oral contraceptive use associates with better mood, showing negative associations with Beck Depression Inventory scores and specific symptoms including feelings of dissatisfaction, uselessness, and irritability. 3

Patients WITHOUT Pre-existing Mental Health Disorders

• A slight increase in depression risk exists for women without previous mental disorders initiating hormonal contraception (RR 1.04, SMD 0.18), though the absolute risk remains small. 1

• Age represents a critical risk factor, with younger women and those initiating contraception at earlier ages showing higher vulnerability to mood effects. 4

• Method-specific risks vary considerably, with hormonal IUDs, implants, and patch/ring methods carrying higher depression risk compared to combined oral contraceptives. 1

Method Selection Algorithm

Preferred Options for Depression/Anxiety History

• Combined oral contraceptives with newer formulations containing physiological forms of estrogen demonstrate weaker links to mood problems compared to older ethinylestradiol-containing pills. 5

• Avoid older oral contraceptive pills containing ethinylestradiol, which link to severe mood problems, particularly those with higher progestogen content. 5

• Long-acting reversible contraceptives (LNG-IUS) show no noteworthy associations with mental health deterioration in current use or duration of use. 3

Methods Requiring Enhanced Monitoring

• Depot medroxyprogesterone acetate (DMPA) requires Category 2 classification (advantages generally outweigh risks) for women with depressive disorders, though use remains acceptable. 2

• Implants and hormonal IUDs demonstrate higher depression risk and antidepressant use rates, necessitating closer follow-up in vulnerable populations. 1

• Patch and ring methods similarly show elevated depression risk compared to oral formulations. 1

Mandatory Screening and Documentation Requirements

Pre-Contraception Assessment

• Screen for mental health disorders including depression, anxiety, and substance use behaviors that might affect contraceptive adherence or increase vulnerability to mood effects. 2

• Document temporal relationships between any previous contraceptive use and mood changes, as this predicts future sensitivity to hormonal effects. 5

• Assess for intimate partner violence, which may influence both contraceptive choice (favoring methods not requiring partner participation like IUDs) and mental health status. 2

• Evaluate substance use patterns (alcohol, prescription abuse, illicit drugs) that interact with both mental health and contraceptive effectiveness. 2

Ongoing Monitoring Protocol

• Refer patients with identified mental health disorders for appropriate psychiatric care before or concurrent with contraceptive initiation. 2

• Monitor for new or worsened depression particularly in the first 3-6 months after initiation, when hormonal effects stabilize. 5

• Consider contraceptive method as causative when temporal relationship exists between initiation and mood deterioration. 5

Special Populations and Contraindications

Lower Income Women with Mental Distress

• Contraceptive patterns differ significantly by income level, with lower-income women with frequent mental distress showing lower odds of using highly effective (aOR 0.5) or moderately effective (aOR 0.6) reversible methods. 6

• Permanent contraception rates increase among women with frequent mental distress (1.4 times higher odds), suggesting potential barriers to reversible method access or tolerance. 6

Pregnancy Considerations

• SSRIs, particularly sertraline, represent first-line treatment for anxiety during pregnancy when contraception fails, with benzodiazepines contraindicated due to neonatal withdrawal and malformation risks. 7

• Untreated maternal anxiety and depression carry substantial risks including premature birth and decreased breastfeeding initiation, often outweighing medication risks. 7

Critical Pitfalls to Avoid

• Do not assume all hormonal contraceptives affect mood identically—progestogen type and dose create vastly different risk profiles. 5

• Do not discontinue effective contraception without psychiatric consultation in women with stable mental health on current methods, as pregnancy itself poses mental health risks. 7

• Do not overlook the protective effects of contraception in preventing unintended pregnancy, which itself induces long-term distress and mental health consequences. 1

• Do not fail to document mental health screening in the medical history, as this represents a potential barrier to correct and consistent contraceptive use requiring referral. 2