Oral Contraceptives and Women’s Mental Health
Emerging research shows how the pill may improve mental health
By Larkin Callaghan
Published September 17, 2013
The use of oral contraceptives for purposes other than birth control is by now a normal practice. The pill is frequently prescribed to those suffering from severe and persistent acne, for the alleviation of severe cramping and endometriosis, and for soothing the symptoms of premenstrual dysphoric disorder and premenstrual syndrome.
In fact, when asking women for the reasons they began using the pill, 82 percent cited non-contraceptive reasons as a major factor, and one third of teens use the pill solely for reasons other than preventing pregnancy.
Of course, the use of the birth control pill at all—for the prevention of pregnancy or other reasons—has unnecessarily become the center of heated political and social debates, despite the fact that millions of American women rely on it. The ability for women to access oral contraception has become increasingly contentious in recent years, with legislators working to outlaw them entirely. So, the mention of another potentially promising side effect of the pill may be immediately—and unfortunately—rebuffed.
And yet, it seems there may be another non-contraceptive reason for using oral contraceptives—the prevention of incident depression and suicidal ideation in young women. While opponents of birth control may claim that there are existing medications for the treatment of depression, the findings of this new research detail even more compelling reasons why oral contraception may benefit the health of women.
According to a study published in this month’s American Journal of Epidemiology by researchers at Columbia University’s Mailman School of Public Health, the steady hormone levels provided by the pill may reduce the risk of depression and suicide attempts in young women. Only a handful of studies have explored this relationship in the past. Two studies in the past decade and half showed no positive or negative effect of hormonal contraceptives on depressive symptoms, while another showed that those using oral contraceptives had reduced depressive symptoms.
“We have long believed that sex-linked hormones such as estrogen are important predictors of mood problems, but little research has addressed how [external] estrogen regulation through hormonal contraceptives may or may not be associated with mental health outcomes,” says Katherine Keyes, Ph.D., lead author of the study and assistant professor of epidemiology at Columbia.
The study authors used a longitudinal—meaning the young women were followed over a period of time—nationally representative sample called the National Longitudinal Study of Adolescent Health (known as Add Health). The Add Health study began in 1992, with a total of 90,000 girls being surveyed about health behaviors in school. Subsequently, 20,000 of these girls were randomly selected for in-depth home interviews, and were given follow-up interviews in 1996 (known as Wave 2), 2000-2001 (Wave 3), and 2007-2008 (Wave 4).
A total of 6,654 young women, now between the ages of 25-34, who completed these interviews and indicated using contraception were used in this study’s analysis. The interviews assessed depression symptoms and previous suicide attempts among the women. At each wave, women were asked about symptoms of depression in the previous week and the symptoms were given a score based on their severity. They were also asked how many times they had attempted suicide in the previous year.
The findings produced compelling results. First, women who used hormonal contraception (birth control pill, the ring, or the patch) were more likely to be younger and have a college degree, less likely to have children, and more likely to engage in other protective health behaviors—like exercising, visiting the dentist, not smoking, and maintaining a lower body mass index.
Second, the women using hormonal contraception had lower scores of past-week depression symptoms, lower odds of high depressive symptoms, and lower odds of having attempted suicide in the last year. This was true even after the authors accounted for previous depressive symptoms among the women. When exploring the data longitudinally—that is, examining the association between contraceptive use and depression over the course of two waves of data to see if there were differences depending on the age of the women—the findings held true. Users of the pill, patch, or ring had lower odds of having high depression scores between the ages of 18 and 28, with even lower odds of a high depression score between the ages of 25 and 34.
Interestingly, hormonal contraception was not protective against a suicide attempts between the ages of 18 and 28, but it was between the ages of 25 and 34.
Dr. Kim Yonkers, professor of psychiatry at the Yale University School of Public Health and an expert on women’s reproductive and psychiatric health, praised the study.
“It’s certainly in line with what data are out there with regard to oral contraceptives, and I think the researchers did a nice job using the information that’s available,” she says.
There are limitations to the study. The authors acknowledge that women who perceive there to be negative side effects in their mood due to hormonal contraception are less likely to maintain its use, and these women may be more prone to depressive symptoms, potentially accounting for some of the findings and partially explaining the link.
As Yonkers says, “it could be a healthy observer effect. They’re talking to a group of women [who were using oral contraceptives] who are more likely to be healthy, to be psychologically healthy, to attend medical appointments; so it’s impossible to assign causality,” which she notes the authors are accurately not doing.
There are also a range of personal factors—like relationship status and sexual comfort—that contribute to a woman’s decision to use the pill, patch or ring, as opposed to using a barrier method such as a condom on its own, or no protection at all.
Hormonal contraception, as noted by the authors, is most commonly used among educated, cohabitating and unmarried white women. This is likely due to a few factors. College educated individuals are more likely to be fully employed and therefore have better health insurance, making the pill more affordable. There are racial disparities due to insurance as well, as white women are more likely to have health coverage than women of color. Funding for public and non-profit organizations that offer oral contraceptives at affordable and sliding scale prices for women without insurance are constantly under threat of—and actually victim to—major cuts in funding. It is unlikely that evidence for protective effects on mental health will ameliorate these differences since they are rooted in access and economics, but the implications of the study are still wide.
For example, Yonkers also points out the influence this study could have on regulations for prescription drugs.
“I think this adds to the body of literature questioning why oral contraceptives have to have this labeling that their compound increases the risk of depression. I don’t think we see that at a population level very strongly. No [older, randomized control] trials have found that oral contraceptives, even at a much higher dose, increase the likelihood of depression, let alone suicidal ideation or suicide,” she says.
This labeling may deter some women from using the birth control pill if they are particularly wary of its influence over their mood stability, when in fact it seems it may benefit mood or at minimum have no effect. The Federal Drug Administration notes that they label drugs based on data derived from human experience wherever possible.
As Yonkers says, “the FDA keeps mandating that this labeling be included on oral contraceptive agents—as a class labeling—despite the fact that we don’t see it in clinical trials. So I think it’s something that has to be taken up more carefully with the FDA.”
Whether data or politics will determine FDA labeling remains to be seen, but this study adds to the mounting evidence that the former should be more greatly weighed.
Edited by Karestan Koenen.