Mental Health Screening Needed for Optimal Contraceptive Counseling
March 1, 2024 4 minutes read
Mental health conditions are common among people of reproductive age. Still, both physicians and patients may have misconceptions about using hormonal contraception if patients are diagnosed with depression or other mental health issues.
New research suggests that barriers to effective contraceptive use should be addressed, and clinicians need to dispel myths about the negative psychiatric impacts of hormonal contraceptives.1
“This was a review of all current and existing literature, and we did this because we know that mental health conditions are a huge proportion of those among reproductive age,” says Hayley M. Miller, MD, lead study author and a fellow in the division of maternal-fetal medicine and obstetrics at Stanford University School of Medicine.
The study highlights the need for reproductive health clinicians to screen patients for mental health issues and to be comfortable with physician resources about specific mental health conditions, she notes.
“This document provides guidance for clinicians who care for those of reproductive age because we know that providers really should be comfortable in discussing and counseling in contraception,” Miller says. “Those who have mental health conditions are more vulnerable to adverse mental health outcomes, so these patients should be prioritized in receiving contraceptive counseling.”
Providers can help patients optimize their medical conditions, such as mental health conditions, before they become pregnant. This could improve perinatal outcomes.
“We know there are many common misconceptions about the use of hormonal contraception among these folks,” Miller says. “We wanted to do a review of the literature to guide clinicians on what is safe and review specific mental health conditions and the impact of contraception on these.”
People with pre-pregnancy depression may find their symptoms worsening during pregnancy and postpartum. Because of the research into the connection between mental health issues and depression related to pregnancy, the American College of Obstetricians and Gynecologists has recommended that providers screen all pregnant patients for mental health conditions.
“We want to encourage that screening to start prior to patients becoming pregnant to optimize their mental health conditions,” Miller says. “Pregnancy leads to physiological changes that may alter mental health conditions.”
Contraceptives could affect some mental health medications, so dosages might need to be adjusted. “We want to make sure we’re following these patients closely so we can continue to assess whatever mood disorder they have,” she adds.
One of the myths is that estrogen can worsen mood disorders like depression, Miller notes. “There isn’t much of an association of estrogen impacting mood disorders,” she says. “Providers sometimes feel uncomfortable because they’re fearful it will worsen [the patient’s] mental health condition because of the hormonal effect.”
But this fear and misconception around estrogen is not supported by evidence, Miller adds. “There are some progestins that may influence certain mood disorders,” she explains. “I would encourage anyone with any mental health condition, if they feel their condition is worsening, to consider alternatives.”
There are many contraceptive options and different dosages that providers can use to optimize mental health conditions. Providers should learn more about the different classes of progestins and how they impact mood disorders, including progestin intrauterine devices (IUDs).
“The overall available evidence demonstrates that hormonal contraceptives are safe to use among those with mental health conditions,” Miller says. “There are special considerations that are needed for people who may be at risk of poor adherence, or who use certain classes of antipsychotics or antiepileptics, or who are less than six weeks postpartum.”
For example, clinicians could recommend contraceptive methods that do not require daily use, such as the contraceptive implant or an IUD, for those at risk of poor adherence, Miller suggests.
“For those who are less than six weeks postpartum, we don’t recommend estrogen-containing contraception because it increases the risk of blood clots and lessens lactation,” she says. “For those on antipsychotics or antiepileptics, there are [medications] that are metabolized by the liver, and contraceptive steroids like estrogen and progestin can impact the serum levels of the medication. There are certain classes that should be considered when prescribing certain types of contraception.”
Patients’ dosages can be adjusted to increase the serum level of the medication to counter the effect of hormonal steroids on the liver, Miller adds.
Providers should use evidence-based resources and the U.S. Medical Eligibility Criteria when making decisions about contraceptives and drug interactions, as well as for contraceptive counseling. The U.S. Medical Eligibility Criteria is a table that lists chronic medical conditions, including mental health conditions. It includes safety information on various contraceptives. The latest version provides recommendations for women with cystic fibrosis, multiple sclerosis, and women using certain psychotropic drugs or St. John’s wort.2
“I would hope most providers are comfortable reading that chart and using that chart with their patients,” Miller says.
The research highlights the importance of screening reproductive health patients for mental health conditions and accessing resources that can be used when counseling patients on their options for specific mental health conditions, Miller notes.
REFERENCES
- Miller HE, Kruger SL, Panelli DM. Mental health conditions and contraception: Current landscape, reproductive health and obstetric outcomes, and clinical guidance. Curr Opin Obstet Gynecol 2024;Jan 3. doi: 10.1097/GCO.0000000000000936. [Online ahead of print].
- Centers for Disease Control and Prevention. US Medical Eligibility Criteria for Contraceptive Use, 2016 (US MEC). Last updated March 27, 2023. https://www.cdc.gov/reproducti...
Mental health conditions are common among people of reproductive age. Still, both physicians and patients may have misconceptions about using hormonal contraception if patients are diagnosed with depression or other mental health issues. New research suggests that barriers to effective contraceptive use should be addressed, and clinicians need to dispel myths about the negative psychiatric impacts of hormonal contraceptives.
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