Hormonal birth control causes depression — is that “fake news” or a legitimate health concern? Even a sampling of relatively mainstream articles turns up contradictory titles: “It’s Not In Your Head: Striking New Study Links Birth Control to Depression” versus “Birth Control Causes Depression? Not So Fast”.
To help sift the sensational from the scientific, I turned to Dr. Sonia Aneja, a board-certified obstetrician-gynecologist at Allegheny Health Network.
In late 2016, JAMA Psychiatry published a Danish study exploring possible links between hormonal birth control and depression. It got picked up by various media outlets, and the Internet soon exploded with discussions about changes in mood caused by contraception.
The study analyzed health data from more than 1 million women ages 15 to 34, over nearly two decades. Among other things, it found that women ages 15 to 19 who took a birth control pill containing both progestin and estrogen had an 80 percent increase in “relative risk” of depression (measured in the study by being prescribed antidepressants or diagnosis in a psychiatric hospital).
News coverage and conversation zoomed in on that finding, but sometimes left out other important details or failed to explain what “relative risk” statistics mean. For some people, the resulting takeaway became: “birth control causes depression.”
“The study shows an association, not a causal relationship,” Dr. Aneja says. She explains that a study may find that two things have a correlation — in this case, women taking hormonal birth control were also more likely to show signs of depression during the study — but that doesn’t automatically mean one caused the other. She adds that one way researchers establish causality — conducting a randomized control trial — isn’t an option when it comes to birth control.
“In a randomized control trial, you would have two groups — one would get birth control pills, and the other would get a placebo, and then you compare the results. That would be unethical in this case,” she says.
Although the Danish study doesn’t rise to that level in proving that birth control causes depression, Dr. Aneja acknowledges that there are legitimate concerns about the side effects of hormonal contraceptives — as there are with many medications. “I don’t think I’d change my practice based on anything in the Danish study, but there is already an awareness from other studies showing associations of increased depression based on increased or fluctuating levels of progesterone or estrogen,” she says.
With that in mind, she noted another study finding: that women who had the Mirena IUD had less relative risk for depression. The Mirena IUD, she explains, involves more localized absorption of the birth control hormones as opposed to the systemic absorption (throughout the whole body) of other methods. “This is consistent with how we counsel patients in general — that methods with less systemic absorption will have fewer systemic side effects,” she says.
Dr. Aneja says the Danish research may help open up a valuable discussion about the potential mental side effects of hormonal birth control, but more studies need to be done before making broader conclusions. In the meantime, she says we should remember that there are significant differences between birth control methods, and that a range of variables should be considered when assessing someone’s risk of depression.
Framing the Danish study as proof that “birth control causes depression” isn’t just technically incorrect, Dr. Aneja says it can lead people to overlook other factors that contribute to a higher risk of depression.
Noting the study’s finding on women ages 15 to 19, for example, Dr. Aneja explains that studies show that adolescents have a higher risk for depression, regardless of birth control. That’s not too surprising when you consider the hormonal changes of puberty, as well as the emotional transitions, tumultuous relationships, and new life pressures generally associated with becoming a young adult.
Dr. Aneja says that we should also consider the influence of social issues surrounding women and health care. “A lot of women seeking contraception to prevent pregnancy may also be dealing with social issues that may make them more vulnerable to depression,” she points out.
She says a correlation between use of birth control and depression could also be tied to access and comfort with the health care system. Some women don’t have access to contraception, because they don’t have access to consistent, quality health care in general, she explains — so they’re also unlikely to be diagnosed or to seek treatment for depression. By contrast, women who acquire hormonal contraception are potentially women who not only have access to health care, but are more inclined to seek care for other health issues — including depression.
For Dr. Aneja, these complexities reinforce the importance of good doctor-patient counseling based on an individual’s medical history. “If someone doesn’t have a history of mental health problems, and there aren’t other risk factors for depression, that might not be the first thing I bring up as we’re talking about birth control, but all potential side effects would be part of the counseling.” On the other hand, she says that, “if a patient has a tendency towards depression, the potential side effects with high doses of progesterone are something to consider. And for women with a history of severe mental health disorders, I would surely bring this up as we discussed hormonal contraception, because prior studies suggest an increased risk of depression with high doses of progesterone.”
Dr. Aneja says that smart contraception decisions should involve a woman and her doctor discussing the woman’s health history, what she wants out of contraception, and certain personal preferences.
“One basic question we ask patients is, ‘do you want a long-acting, reversible contraceptive like an IUD, or do you want something that you have more agency in controlling, like taking a pill every day or putting a patch on every week?’” she says. “If you’re thinking of having a baby within the next six months to a year, then something more short-term may be better, like birth control pills, the patch, or the ring. But if you’re not planning to have children over the next three to five years, a long-acting, reversible contraception method may be more in line with your life goals.”
Similarly, potential side effects vary, and should be part of the decision. “It’s important to look at all the pros and cons, including the side effects, of different contraceptives to figure out what works best for you given your medical history and personal preferences,” she says. “For example, an IUD may come with a higher chance of irregular bleeding. That’s a side effect some women are not ok with; other women are ok with irregular bleeding, but, although it’s not exactly data supported, they may be concerned about possible weight gain and mood changes they’ve heard associated with hormonal birth control pills. We want to make sure all the possible risks, benefits, and side effects are known, and then use your personal preferences, lifestyle, and medical history to guide us to the right decision for you.”
Dr. Aneja wants each patient to feel well-informed and confident in making her own decision. “The ultimate goal is that you get pregnant when you want to get pregnant,” she says. “These options exist so that you are empowered and have control over your reproductive life. Our job as doctors is to help guide you through those options.”
That brings us back to the fundamental challenge that inspired me to research and write this article. We can only make good health decisions if we base them on accurate, reliable information. What is easiest to find with an online search and what gets the most attention on social media may not always be accurate and reliable. And, as the birth control and depression issue shows, even scientific studies can be misunderstood or “spun” in different ways. When in doubt, talk to your doctor or someone whose expertise you trust. (If you’re a Highmark health plan member, don’t forget that you can get help from Blues On Call experts by calling 1-888-258-3428.)
I also spoke with Dr. Aneja to get more general tips for understanding medical information and making good health decisions — so stop back to the Highmark Health blog to read that article in the near future!
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