Robin C. Kopelman, M.D., M.P.H. Clinical Assistant Professor, University of Iowa Department of Psychiatry Co-Director, Women’s Wellness and Counseling.

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