Contraception for patients with mental health conditions

Mental health conditions affect about 1 in 7 people globally.¹ Anxiety and depressive disorder account for most cases. Reproductive-age females are more likely to be affected by depression and anxiety disorders than men, with an age-standardized prevalence of 24% among women vs 13.3% among men in the US.² Those who are pregnant or who are recently in the postpartum period are increasingly at risk; depressive disorders diagnosed during US delivery hospitalizations increased 7-fold from 4.1 diagnoses per 1000 hospitalizations in 2000 to 28.7 diagnoses per 1000 hospitalizations in 2015.³ Perinatal mental health conditions are associated with adverse outcomes for the pregnant or postpartum person as well as fetus, infant, partner, or family.⁴ Additionally, perinatal depression may signal a trajectory for chronic depression and its lasting implications.⁵

Mental health conditions also impact pregnancy prevention. In the US, nearly half of all pregnancies are unintended, and people with mental health conditions may face increased risk.^6,7 One contributing factor may be that there is an overlap between those at risk of mental health conditions and those at risk for contraceptive nonuse or misuse.⁸ Additionally, symptoms of depression or anxiety might affect contraceptive decision-making and result in increased use of highly user-dependent methods such as condoms.⁹ Studies show that some patients with mental health symptoms or diagnoses are at an increased risk for contraceptive failure when using highly user-dependent methods,¹⁰ and may be more likely to undergo early removal of long-acting reversible contraceptive (LARC) methods such as an intrauterine device (IUD) or implant.¹¹ If unintended pregnancy occurs, the prevalence of perinatal depression is 2 times higher than in those with an intended pregnancy.¹²

Given the intersection of reproductive and mental health, assessment of family planning goals may be an important tool in improving the overall mental health of those capable of becoming pregnant. When counseling a patient with a mental health condition on contraceptive options, providers should consider several factors, including the following: safety (eg, method-specific impact on mood), effectiveness (eg, medication interactions and the patient’s ability to use the method consistently and correctly), population-specific concerns such as those in adolescents and postpartum patients, adverse effects, and noncontraceptive benefits (eg, use in premenstrual dysphoric disorder).

Effects of contraception on mental health

Although the cause of mental health conditions and the relationship between mood changes and hormonal contraception is not fully understood physiologically, synthetic estrogens and progestins could theoretically interact with serotonergic or noradrenergic systems and, therefore, impact mood.¹³ Although the data are limited and research gaps exist, the available evidence suggests that there is not a causal relationship between hormonal contraception and worsening mental health symptoms.^13-15 In fact, some studies show positive changes in mood-related outcomes in patients taking hormonal contraception.^16,17 Confounding variables in the relationship between hormonal contraception and mood symptoms may include a heightened awareness or altered perception of adverse effects due to symptoms of depression or anxiety.¹⁸ Despite the lack of an evidence-based causal relationship, the perception of hormone-related mood symptoms continues to be a commonly reported adverse effect and reason for method discontinuation.^18,19

Contraceptive options for patients with mental health conditions

Although some specific considerations exist, all contraceptive methods generally are safe for use in patients with mental health conditions. The US Medical Eligibility Criteria for Contraceptive Use (US MEC) provides evidence-based safety recommendations for the use of methods by patients with specific characteristics or medical conditions such as depressive disorders and those on medications used in depressive disorder, bipolar disorder, and other mental health conditions.²⁰ Eligibility categories are assigned to each characteristic or condition: categories 1 and 2 are generally considered safe for use, category 3 represents a relative contraindication and may warrant consultation with a specialist, and category 4 represents an absolute contraindication. In the recently updated 2024 US MEC, there are no restrictions for the use of hormonal contraceptives for patients with depressive disorders, and all contraceptive options are listed as category 1. Patients on medication therapy are considered in more detail below.

Other nonhormonal contraceptive methods are also safe for people with mental health conditions. Examples include fertility awareness–based methods, condoms, diaphragm, withdrawal, spermicide, and vaginal pH–modulating gel. Permanent contraceptive procedures are available for patients who do not desire future fertility and are surgical candidates. Finally, emergency contraception is generally safe for all patients, including those with mental health conditions.

Special considerations and populations

Concomitant medication use

Depressive and anxiety disorders are commonly treated with selective serotonin reuptake inhibitors or selective norepinephrine reuptake inhibitors, and these medications do not interact with the metabolism of hormonal contraceptives (Table).²¹ Conversely, some historically used medications such as tricyclic antidepressants, monoamine oxidase inhibitors, and St John’s wort (Hypericum perforatum), as well as some anticonvulsant medications used to treat bipolar disorders (eg, lamotrigine and carbamazepine), are inducers of the liver cytochrome p450 enzyme system. When these medications are taken in conjunction with contraceptive hormones, interactions could theoretically lead to decreased contraceptive efficacy or increased systemic exposure to the psychotropic medication.^21,22 To address contraceptive efficacy concerns, the use of an IUD or depot medroxyprogesterone acetate (DMPA) injection may be the preferred choice for patients using these specific medications, or concomitant barrier contraception use may be recommended. Collaborative consultation with a complex family planning specialist and psychiatrist may be warranted for further guidance.

Adolescents

Conflicting evidence exists regarding a potential increased incidence of depression among adolescents using hormonal contraceptive methods. A prospective cohort study in Denmark demonstrated an increase in depressive symptoms among adolescents who used hormonal contraceptives compared with nonusers, as well as an association between hormonal contraceptive use and subsequent future use of antidepressant medications.²³ In the US, a cross-sectional survey of over 10,000 adolescents, of which 4700 adolescents reported current or past oral contraceptive use, found no relationship between ever using an oral contraceptive pill and lifetime depressive disorder (OR, 1.10; 95% CI, 0.88-1.37) and no relationship between current use of oral contraceptives and current depressive disorder (OR, 0.82; 95%, CI 0.50-1.35).²⁴

Currently, the US MEC does not restrict contraceptive options for adolescents or young adults.²⁰ Overall, hormonal contraception is safe for adolescents; however, clinicians should address the possibility of mood symptom adverse effects and consider alternative methods if a patient or their guardian is concerned. These encounters can also be an opportunity to screen adolescents for underlying mental health conditions and identify patients who would benefit from referrals to behavioral and psychiatric health specialists.

Patients in the postpartum period

Given the prevalence and significance of perinatal mental health conditions, some providers and patients may have concerns about hormonal contraception initiation in the postpartum period. A retrospective analysis of postpartum depressive events recorded in the US Food and Drug Administration Adverse Event Reporting System database between 2004 and 2015 found that the use of hormonal contraceptives may convey an increased risk for postpartum depression.²⁵ In response, a systematic review investigated this further.²⁶ Two studies in the review found no differences in the rate of postpartum depression among patients using DMPA injections and those not using hormonal contraception. Another included study compared combined hormonal contraceptives, progestin-only pills (POPs), etonogestrel implants, and levonorgestrel IUDs with nonhormonal contraception and found a 35% to 44% decreased risk of postpartum depression among patients using POPs and levonorgestrel IUDs. Overall, this systematic review concluded that there was no consistent association between hormonal contraceptive use and the incidence of postpartum depression. Given these reassuring data, clinicians should not withhold offering the full spectrum of contraceptive options to patients in the postpartum period based on concern for mood-related outcomes.

Patients with premenstrual dysphoric disorder

Psychiatric disorder premenstrual dysphoric disorder (PMDD) is characterized by emotional symptoms of affective lability, irritability or anger, depressed mood, or anxiety that present in the final week before the onset of menses and improve during menses.²⁷ Although an exacerbation of a preexisting mental health disorder should be ruled out, the onset of these symptoms, specifically during the luteal phase, is symptomatic of PMDD and can occur concurrently with any mental health disorder. Combined oral contraceptives (COCs) that contain the progestin drospirenone, such as Yaz, Yasmin, and their generic counterparts, are approved for the treatment of PMDD and should be considered when treating a patient with PMDD who prefers an oral contraceptive.²⁸ Another consideration when prescribing combined hormonal contraceptives for patients with cyclic mood symptoms is to use a monophasic formulation to maintain a steady hormone state. The use of extended or continuous formulations may also be useful in reducing the number of hormone withdrawal intervals a patient experiences, which can exacerbate mood symptoms.²²

Counseling

A patient’s decision to initiate or continue a specific type of contraceptive is multifactorial and often influenced by concern for or experience of an unfavorable adverse effect. Discontinuation rates of COCs for perceived mood symptoms range from 14% to 21% in some studies.¹⁸ Patients with mental health conditions may also be concerned about sexual dysfunction adverse effects. Not only are many sexual disorders related to depression, but many of the medications used to treat depression can also decrease libido. Although data on the direct association between COCs and sexual function is conflicting, emotional and sexual adverse effects are strong predictors of contraceptive discontinuation.²⁹ Therefore, it is important to address potential adverse effects up front and counsel patients on alternative options if they remain concerned about these symptoms.

As part of shared decision-making, clinicians can help patients choose a method that best fits their schedule and lifestyle. Patients with anxiety or depression may take daily medication. To assess their preference for, and probability of adherence to, a daily contraceptive, a provider can ask whether they have issues remembering to take their current medications. It is also important to screen for intimate partner violence (IPV), as patients who experience IPV often suffer from mental health conditions. Contraception sabotage, such as a partner’s refusal to use condoms or tampering with contraceptive pills, is associated with IPV. Patients experiencing contraception sabotage or IPV may prefer discreet methods such as an IUD or injection. Some patients with mental health conditions may have a more difficult time accessing health care. Therefore, 12-month prescribing of contraceptives or placement of a LARC method may help reduce these barriers. Although some patients may want a LARC method, patients with mental health conditions may have a distrust of the medical system and prefer an option that can be initiated or discontinued without the assistance of a health care provider.

Special ethical counseling consideration is needed for patients with debilitating psychiatric disorders such as schizophrenia. Even when a patient is determined to have decision-making capacity, it is still necessary that providers assess for coercion from a caregiver or other family member. Implicit biases, including attitudes and stigmatization of people with mental health conditions, may influence how patients with these conditions are counseled on their contraception options. The use of a patient-centered contraception counseling model can help explore a patient’s reproductive and contraception goals to help reduce contraception coercion behaviors.³⁰

Screening for psychiatric disorders

Mental health disorders are often underdiagnosed or undiagnosed.²⁹ Obstetrician-gynecologists and other clinicians who prescribe contraception can play a role in screening patients for these conditions. Patients may have difficulty disclosing their mental health symptoms, and due to time constraints, it may be challenging for clinicians to dedicate a significant amount of time to addressing mental health concerns. The use of a standardized mental health screening instrument, however, can be one feasible option to screen patients for depression and anxiety and identify those who need follow-up psychiatric care. The American College of Obstetricians and Gynecologists recommends screening every patient receiving well, or pregnancy-related care using such an instrument.⁴ Clinicians should provide immediate assessment and arrange for risk-tailored management for any patient who answers affirmatively to a self-harm or suicide screen.

Conclusion

Mental health disorders, especially anxiety and depressive disorders, are common in reproductive-age women. The ability to prevent or space pregnancy using contraception may contribute to patient health and well-being. Based on the available evidence, the current recommendations do not limit contraceptive options in patients with mental health disorders. However, considerations for concomitant medication use and adverse effects may be necessary. Consultation with a complex family planning specialist is helpful in some cases. As with all patients, shared decision-making regarding contraceptive use and options is recommended. Additionally, contraceptive care is an important access point to screen for mental health disorders and assess patient safety.

References

1. 2021 global burden of disease study results. Institute for Health Metrics and Evaluation. Accessed November 27, 2024. https://vizhub.healthdata.org/gbd-results/
2. Lee B, Wang Y, Carlson SA, et al. National, state-level, and county-level prevalence estimates of adults aged≥18 years self-reporting a lifetime diagnosis of depression—United States, 2020. MMWR Morb Mortal Wkly Rep. 2023;72(24):644-650. doi:10.15585/mmwr.mm7224a1
3. Haight SC, Byatt N, Moore Simas TA, Robbins CL, Ko JY. Recorded diagnoses of depression during delivery hospitalizations in the United States, 2000-2015. Obstet Gynecol. 2019;133(6):1216-1223. doi:10.1097/AOG.0000000000003291
4. Screening and diagnosis of mental health conditions during pregnancy and postpartum: ACOG Clinical Practice Guideline No. 4. Obstet Gynecol. 2023;141(6):1232-1261. doi:10.1097/AOG.0000000000005200
5. Najman JM, Plotnikova M, Williams GM, et al. Trajectories of maternal depression: a 27-year population-based prospective study. Epidemiol Psychiatr Sci. 2017;26(1):79-88. doi:10.1017/S2045796015001109
6. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med. 2016;374(9):843-852. doi:10.1056/NEJMsa1506575
7. Judge-Golden CP, Borrero S, Zhao X, Mor MK, Callegari LS. The association between mental health disorders and history of unintended pregnancy among women veterans. J Gen Intern Med. 2018;33(12):2092-2099. doi:10.1007/s11606-018-4647-8
8. Frost JJ, Singh S, Finer LB. Factors associated with contraceptive use and nonuse, United States, 2004. Perspect Sex Reprod Health. 2007;39(2):90-99. doi:10.1363/3909007
9. Garbers S, Correa N, Tobier N, Blust S, Chiasson MA. Association between symptoms of depression and contraceptive method choices among low-income women at urban reproductive health centers. Matern Child Health J. 2010;14(1):102-109. doi:10.1007/s10995-008-0437-y
10. Stidham Hall K, Moreau C, Trussell J, Barber J. Young women’s consistency of contraceptive use—does depression or stress matter? Contraception. 2013;88(5):641-649. doi:10.1016/j.contraception.2013.06.003
11. Bello JK, Salas J, Meyer D, et al. Mental health diagnoses and early removal of long-acting reversible contraception. J Affect Disord. 2020;262:333-336. doi:10.1016/j.jad.2019.11.046
12. Abajobir AA, Maravilla JC, Alati R, Najman JM. A systematic review and meta-analysis of the association between unintended pregnancy and perinatal depression. J Affect Disord. 2016;192:56-63. doi:10.1016/j.jad.2015.12.008
13. Pagano HP, Zapata LB, Berry-Bibee EN, Nanda K, Curtis KM. Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review. Contraception. 2016;94(6):641-649. doi:10.1016/j.contraception.2016.06.012
14. Kraft MZ, Rojczyk P, Weiss T, et al. Symptoms of mental disorders and oral contraception use: a systematic review and meta-analysis. Front Neuroendocrinol. 2024;72:101111. doi:10.1016/j.yfrne.2023.101111
15. Robinson SA, Dowell M, Pedulla D, McCauley L. Do the emotional side-effects of hormonal contraceptives come from pharmacologic or psychological mechanisms? Med Hypotheses. 2004;63(2):268-273. doi:10.1016/j.mehy.2004.02.013
16. Westhoff C, Truman C, Kalmuss D, et al. Depressive symptoms and Depo-Provera. Contraception. 1998;57(4):237-240. doi:10.1016/s0010-7824(98)00024-9
17. Almagor M, Ben-Porath YS. Mood changes during the menstrual cycle and their relation to the use of oral contraceptive. J Psychosom Res. 1991;35(6):721-728. doi:10.1016/0022-3999(91)90123-6
18. Hall KS, White KO, Rickert VI, Reame N, Westhoff C. Influence of depressed mood and psychological stress symptoms on perceived oral contraceptive side effects and discontinuation in young minority women. Contraception. 2012;86(5):518-525. doi:10.1016/j.contraception.2012.04.010
19. Martell S, Marini C, Kondas CA, Deutch AB. Psychological side effects of hormonal contraception: a disconnect between patients and providers. Contracept Reprod Med. 2023;8(1):9. doi:10.1186/s40834-022-00204-w
20. Nguyen AT, Curtis KM, Tepper NK, et al; Contributors. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024;73(4):1-126. doi:10.15585/mmwr.rr7304a1
21. Berry-Bibee EN, Kim MJ, Simmons KB, et al. Drug interactions between hormonal contraceptives and psychotropic drugs: a systematic review. Contraception. 2016;94(6):650-667. doi:10.1016/j.contraception.2016.07.011
22. Hall KS, Steinberg JR, Cwiak CA, Allen RH, Marcus SM. Contraception and mental health: a commentary on the evidence and principles for practice. Am J Obstet Gynecol. 2015;212(6):740-746. doi:10.1016/j.ajog.2014.12.010
23. Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of hormonal contraception with depression. JAMA Psychiatry. 2016;73(11):1154-1162. doi:10.1001/jamapsychiatry.2016.2387
24. 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
25. Horibe M, Hane Y, Abe J, et al. Contraceptives as possible risk factors for postpartum depression: a retrospective study of the Food and Drug Administration adverse event reporting system, 2004-2015. Nurs Open. 2018;5(2):131-138. doi:10.1002/nop2.121
26. Ti A, Curtis KM. Postpartum hormonal contraception use and incidence of postpartum depression: a systematic review. Eur J Contracept Reprod Health Care. 2019;24(2):109-116. doi:10.1080/13625187.2019.1569610
27. Reid RL. Premenstrual dysphoric disorder (formerly premenstrual syndrome). In: Feingold KR, Anawalt B, Blackman MR, eds. Endotext [Internet]. MDText.com, Inc; 2000-. https://www.ncbi.nlm.nih.gov/books/NBK279045/table/premenstrual-syndrom.table1diag/
28. Ma S, Song SJ. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev. 2023;6(6):CD006586. doi:10.1002/14651858.CD006586.pub5
29. Krapf JM, Goldstein AT. Combined estrogen-progestin oral contraceptives and female sexuality: an updated review. Sex Med Rev. 2024;12(3):307-320. doi:10.1093/sxmrev/qeae011
30. American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women, Contraceptive Equity Expert Work Group, and Committee on Ethics. Patient-centered contraceptive counseling: ACOG Committee Statement Number 1. Obstet Gynecol. 2022;139(2):350-353. doi:10.1097/AOG.0000000000004659