Is Progestin-Based Contraception Linked to Depression?

BACKGROUND AND PURPOSE: 

• Weight gain, acne, mood changes and depression have been listed as possible side effects of progestin-based contraceptive methods  
• Worly et al. (Contraception, 2018) performed a systematic review to measure the association between progestin-only contraception and depression 

METHODS: 

• Systematic Review 
• Search included progestin-only contraception and depression, focusing on externally validated depression measures 
• Study quality was evaluated using USPSTF and the Cochrane Risk of Bias Tools 
• Study questions were as follows 
  • Is there an association or causative link between progestin-only hormonal contraception and depression? 
  • Does the type of progestin or route of administration influence such an association? 
  • Are there certain populations (e.g., adolescents, postpartum patients or women with a history of depression) in which this association exists?

RESULTS: 

• 26 studies met inclusion criteria 
  • 5 randomized controlled trials 
  • 11 cohort studies 
  • 10 cross-sectional studies 
• There was minimal association between progestin-only methods and depression 
• Subdermal implants  
  • In five low-quality, high-risk-of-bias studies, there was no correlation between depression and subdermal implants  
• Levonorgestrel IUD  
  • Four out of five varying-quality and medium-risk-of-bias studies there was no association  
  • One large population based study found an association, but was retrospective with a weak association and “evidence is unimpressive”  
• Two progestin-only contraceptive pill studies with varying levels of quality and bias indicate no increase in depression scores 
  • One study demonstrated a lower depression scores but had a small sample size 
  • One larger population based study did find slight increased risk but retrospective and higher dose formulations   
• Medroxyprogesterone acetate intramuscular injection  
  • Trials had varying levels of quality and bias, but overall show no difference in depression 

CONCLUSION: 

• Difficult to derive definitive conclusions, but currently, there is no significant evidence to support an increased risk for increased depression with progestin contraception 
• A minority of users may experience depression, but this effect was not seen in more robust studies  
• Adolescents were likewise not found to have increased risk for depression  
• It is important to continue to measure associations between progestin contraception and mental health 

Learn More – Primary Sources:  

The relationship between progestin hormonal contraception and depression: a systematic review 

Does Maternal Depression or Stress Affect Fetal Growth?

BACKGROUND AND PURPOSE: 

• Intrauterine fetal growth restriction (FGR or IUGR), defined as weight below the 10th percentile, has been associated with excessive maternal stress 
• Most studies are based on birth weight, and therefore cannot fully assess timing of various exposures in addition to confounders  
• Grobman et al. (Journal of Ultrasound in Medicine, 2017) sought to determine whether women reporting greater perceived stress or depression symptoms at start of or during pregnancy would demonstrate altered longitudinal fetal growth 

METHODS: 

• NICHD Fetal Growth Study multicenter prospective (2009 – 2013) 
• Women screened at 8 weeks and 13 weeks 6 days gestation for stress/depression status and underwent serial sonographic examinations
• Definition of high risk 
  • Cohen Perceived Stress Scale (PSS):  Score ≥ 15
  • Edinburgh Postpartum Depression Survey (EPDS): Score of ≥ 10 (13 used for sensitivity analysis)
• Fetal weight growth curves and individual biometric parameters were created using serial sonographic data  
• Interaction between race/ethnicity and stress/depression scores were assessed 

RESULTS: 

• Multicenter longitudinal study of 2334 women 
• 89% and 90% of women completed PSS and EPDS, respectively, at least once in all trimesters 
• Despite participant’s reported PSS or EPDS score, longitudinal growth curves and fetal weight were similar 
• Race/ethnicity did not modify biometric parameters 

CONCLUSION: 

• Quantified depressive symptoms and greater perceived stress are not associated with alterations in fetal growth throughout all three trimesters 
• Authors recommend further research to determine whether combination of stress and/or depression with environmental factors may alter fetal growth 
• This paper complements the Wing et al. study that likewise did not find an association between perceived maternal stress and neonatal growth measurements (summarized in ‘Related ObG Topics’ below) 

Learn More – Primary Sources:  

Maternal Depressive Symptoms, Perceived Stress, and Fetal Growth

Screening for Perinatal Depression

Perinatal depression is defined as major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery.  It is very common, affecting approximately 9% of women in pregnancy and up to 37% at any point in the first year postpartum

Clinical Actions

USPSTF (2019) recommends that

…clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions (Grade B Guidance)

Moderate net benefit

Note: Definition of Grade B Guidance

• The USPSTF recommends the service | There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial
• Suggestions for Practice: Offer or provide this service
• Recommendation based on ‘convincing evidence’
  • Counseling interventions (e.g., cognitive behavioral therapy and interpersonal therapy) are effective in the prevention of perinatal depression

ACOG recommendations include the following

• ObGyns and other obstetric care providers should screen patients for perinatal depression and anxiety “at the initial prenatal visit, later in pregnancy, and at postpartum visits”
• Use a validated screening tool to identify the presence of depression or anxiety

Antepartum Depression Risk Factors

FACTOR	STRENGTH OF ASSOCIATION
Maternal anxiety	Medium – Large
Negative life events	Medium – Large
Unintended pregnancy	Medium
Medicaid (US)	Medium
Poor relationship quality	Medium
History of depression	Medium
Domestic violence	Small – Medium
Lack of social support	Small – Medium
Smoking	Small
Lower income	Small
Lower education	Small

Postpartum Depression Risk Factors:

• Depression during pregnancy
• Anxiety during pregnancy
• Experiencing stressful life events during pregnancy or the early postpartum period
• Traumatic birth experience
• Preterm birth/infant admission to neonatal intensive care
• Low levels of social support
• Previous history of depression
• Breastfeeding problems
• Multiparity

Synopsis:

Left untreated, the results of depression can be devastating for both the child and the mother. Proactive screening is necessary because often depression can go unnoticed. Changes in libido, mood and sleep may incorrectly be attributed to the pregnancy or the birth of the child rather than underlying depression

Key Points:

• Screening alone has potential for clinical benefit In the context of a positive screening test, follow up with appropriate medical interventions and referrals provides maximal benefit
• Gauge depression by paying attention to flat affect, noting unusual anxiety or tearfulness in addition to using a screening instrument
• Anxiety and insomnia can be significant indicators of depression
• Women with a history or with common risk factors for depression are more likely to be affected by perinatal depression and extra caution is warranted
• Management including evaluation and close follow up are required for women with
  • Current depression or anxiety
  • History of perinatal mood disorders
  • Risk factors for perinatal mood disorders
  • Suicidal ideation
• The Edinburgh post-natal depression scale (EPDS) and the PHQ-9 screening tool (see ‘Learn More – Primary Sources’ below)
  • Are validated for use in the primary care setting
  • Take a relatively short time to complete
  • EPDS: Sensitivity 55% to 98% | Specificity 68% to 97%
  • PHQ-9: Sensitivity 53% to 77% | Specificity 85% to 94%
• Other screening tools, unlike the EPDS, include constitutional symptoms
  • Constitutional symptoms such as altered sleep patterns are associated with pregnancy/postpartum period in general, and therefore can reduce screening specificity
• Systems should be in place to ensure follow up, diagnosis and treatment

Learn More – Primary Sources:

ACOG Clinical Practice Guideline 4: Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum

ACOG Guide for Integrating Mental Health Care into Obstetric Practice

USPSTF Recommendation Statement (JAMA): Interventions to Prevent Perinatal Depression

USPSTF Perinatal Depression: Preventive Interventions (2019) 

Edinburgh Postnatal Depression Scale

PHQ-9 Screening Tool

American Psychological Association: Depression Assessment Instruments

Risk factors for depressive symptoms during pregnancy: a systematic review

Risk factors in pregnancy for post-traumatic stress and depression after childbirth

USPSTF: Final Recommendation Statement: Depression in Adults – Screening