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Robin C. Kopelman, M.D., M.P.H.Clinical Assistant Professor, University of Iowa
Department of PsychiatryCo-Director, Women’s Wellness and Counseling Service
Iowa Depression and Clinical Research CenterSeptember 17, 2013
Mental Health and Contraception
Overview
Epidemiology of mood disorders in womenReproductive hormones and mood in
womenMood effects of hormone-based
contraceptionMood symptoms and contraceptive useContraception and preconception
counseling
Major Depressive Episode: Diagnostic Criteria 5 of 9 symptoms, including 1 or 3
(SIGECAPS) 1 depressed mood2 thoughts of death, Suicidal ideation 3 anhedonia or diminished Interest4 worthless or Guilty 5 fatigue, loss of Energy 6 poor Concentration, indecisiveness 7 change in Appetite8 Psychomotor retardation or agitation9 change in Sleep (insomnia or hypersomnia)
Depression: A “women’s issue”
Overall rates: 12% per year, 20% lifetime
Compared to men: 2 – 3 times more common
Difference starts in adolescence
Premenstrual depression/anxiety
Depression during pregnancy
Depression during the postpartum period
Menarche MenopausePregnancy
Depression associated with infertility,
miscarriage, or perinatal loss
Depression/anxiety during the
perimenopausal period
Depression Across the Female Reproductive Cycle
CONTRACEPTION
Not just hormones…
Reproductive hormones are neuroactiveProgesterone and metabolites
GABA
Estrogen and progesteroneMAOOpioid, serotonergic, cholinergic NTs
Not simple relationship to moodU shaped dose-responseFluctuations, not absolute levels
What do we see clinically?Premenstrual Dysphoric Disorder
Depressive symptoms confined to luteal phase
3 – 8 % of women of reproductive age
EtiologyDecreased luteal phase serotonin activity related to hormone shifts (progesterone)
PMS ≠ PMDD
O'Hara, 1986; O'Hara & Swain, 1986; Hobfoll et al., 1995; Seguin et al., 1999
Antenatal Depression
10 – 20% of women during pregnancy Select group - role
for hormones
Bonari et al 2004;Kelly et al., 1999; Kelly et al., 2002;Deave et al., 2008
Untreated Antenatal Depression
Inadequate prenatal care
Low birthweight, preterm delivery, spontaneous AB, bleeding, preeclampsia/gestational hypertension, fetal
death
Behavior issues in neonate
Developmental effectsin children
Increased use of alcohol, drugs, and cigarettes
Postpartum Blues
Common (70 – 80% of women)
Linked to hormone shifts10 days to 2 weeks
Peaking at 5 days
Associated factorsPMDDDepression
Postpartum Depression (PPD)
10-20% of Childbearing Women
Select PPD Risk Factors
Family history 4 – 8 weeks postpartum
History of PMDD
Implication: hormone shifts play a role
Untreated PPD
Inconsistent birth control use*
Less likely to engage in healthy parenting practices
Negative impact on FamilyDevelopmental, behavioral, and
emotional problems in children
Personal suffering of the mother Suicide – a leading cause of maternal death
Why do women not use contraception?Affective symptoms cited as a major
reason for contraceptive discontinuation
Historically change in mood “one of the most common reasons”Study of 79 women – 47% discontinued
oral contraceptives within 6 months, 1/3 due to mood changes
Oinonen & Mazmanian 2002; Sanders et al. 2001
Are mood symptoms a reason to avoid hormonal contraception?Bottom line:
Results conflictingRandomized controlled trials on mood
effects limitedMood effect profile may be largely
favorable for most women
Tori
27 yo female seen in gyn for painful menses, contraception
Has a history of depressionCurrently without mood symptomsReports that oral contraceptives
make mood symptoms worse and bouts more frequent
“What’s my best option?”
Depot medroxyprogesterone acetateLabel warns against use in pts w/
depr hx1.5% of 4200 users reported depression,
0.5% d/c’d use because of depr
16,000 women, 5.4% users vs. 2.3% non-users had mood disorders
Rapkin & Sonalkar 2011; Meirik et al. 2001
Depot medroxyprogesterone acetateStudies limited and conflicting
393 women, 56% d/c’d by 1 year, no increase in depr among cont or d/cers
63 adolesc (dmpa & controls) – no depr
Role of choice - profile of depot users
Rapkin & Sonalkar 2011;Gupta et al. 2001
Levonorgestrel
910 women with LNG implant – 93 drop-outs had higher depr scores, continuers - no increase depression scores at 6 months
Oral LNG = 2 studies, used in combo with EE, no evidence of mood sx
Intrauterine3100 women, 212 IU users, no assoc with
scores or depr dxLower serum levelMaybe good option
Westhoff 1998;O’Connell et al 2007;Rapkin & Sonalkar 2011; Toffol 2011
Lisa
36 yo woman, recently hospitalized for anxiety and new episode severe depression, now partially remitted
No history of premenstrual mood symptoms
Considering pregnancy, but not for a few months
“Would using hormonal contraception make my depression worse?”
Some data suggest - maybe…
Individual characteristics may play a roleHistory of depression
Possible premenstrual worsening
History of premenstrual mood symptomsHistory of perinatal depressionHistory of dysmenorrheaPsychological distress level
Oinonen & Mazmanian 2002
Oral contraceptives – Evidence for no association20,000 women no differences in
depressive symptoms users vs. non-users3100 women, 181 users, no association
with mood symptoms151 women,
combo/progestin-only/placebo, no between group differences
76 women, OCP/Placebo, no difference between groups
Duke et al. 2007; Toffol et al 2011;Graham et al. 1995;O’Connell 2007
Oral contraceptives – evidence for mood benefitsAdolescent girls, placebo vs. OC,
depression scores improvedCombo (estr/prog) may improve
mood in women with MDD1238 women - combo vs. progestin-only
vs. noneCombo had lower depression severity
Attributed to ethinyl estradiol
O'Connell et al. 2007;Young et al. 2007
Erin
20 yo woman, followed for depression in pregnancy. Now 1 week postpartum.
Mild depressive symptoms.Does not want to use intrauterine,
injectable, or barrier methods.“Will mini-pill make my depression
worse?”
Oral contraceptives – CompositionHigher progestin more mood
symptomsData mixed, but overall studies of
progestin-only or higher progestin = greater # and severity depression symptoms
Lower progestin/estrogen ratio may be better
Postpartum depression & progestin-only contraceptionLong-acting norethistherone
enanthate (progestogen only, non-US)
Increased depressive symptoms compared to placebo 6 wks postpartumNo difference at 12 wks
Caution warranted?
Angie
History of premenstrual mood symptoms, dysmenorrhea
Referred to gyn for symptom management
Reported worsening of mood with OCPs, self-harm ideation escalatingCharting data indicated an independent
major depressive episode
“What should we do next?”
SSRIsDosing
ContinuousLutealDepression - both
Hormonal treatmentGNRH agonists, SubQ or transdermal estrogenOral Contraceptives (Yaz)
Drosperinone/Ethinyl Estradiol vs. placebo
Contraception ConsiderationsMay be at increased risk for mood sx
Premenstrual Dysphoric Disorder Treatment
LutealFollicular
fluoxetine 40 mg fluoxetine 20 mg
Depression & use of contraception“Survivor” effects
Psychological symptoms predict:contraceptive nonuseuse of less effective methods
Depression impacts perceptions of provider communicationLimits self-efficacy
Barnet et al. 2008; Carvajal et al 2012;Hall et. al 2013
Perinatal depression & use of contraception Perinatal depression may affect:
Contraception useBirth spacing
Adolescents and women with low-education levels may be particularly vulnerable
Patchen & Lanzy 2013; Faisal-Cury et al 2013;Barnet et al. 2008; Bennett et al. 2005
Counseling our patients
Acknowledge hormones play a role in mood symptoms
Most women will not develop mood symptoms related to contraception
Counseling women with depressionMany reasons to avoid unanticipated
pregnancyDepression impacts pregnancy intervals
and outcomes, child outcomes
Risks of contraceptives for women with depression, as well as benefits, may direct to specific options
Depression affects:
Health behaviors, like contraception useChoice of contraception
Perceptions of provider communication
Screen for and treat depression in women
Other common disorders
SchizophreniaEstrogen may be beneficial
Bipolar disorderAs many as 40% not using contraceptionPerinatal period = high risk – relapse,
psychosisSeveral BPAD treatments -- known
teratogens
Adherence an important issue
What if we need help?Clinical Resource
University of Iowa Women’s Wellness and Counseling Service –
UIHC, Iowa River Landing
Referrals to the WWC
Perinatal and reproductive Perinatal and reproductive psychiatry referralspsychiatry referrals
Phone 319-335-2464Phone 319-335-2464
http://www.uihealthcare.org/womenswellness/
Consultation and Support Resource
Iowa Perinatal Mental Health Consultation Service
Patient & Provider Resource
Summary
Hormones influence moodContributor to common disorder in women
Guiding data is limitedDepression influences contraceptive
choices and related behaviorsMood symptoms should be always be
evaluated and treatedResources available