Depressive symptoms not tied to DMPA, Norplant
Do concerns about possible mood changes lead to you to withhold Depo Provera (DMPA) or Norplant from patients? Results from two analyses from a large prospective study offer reassurance that neither progestin-only method causes or exacerbates depressive symptoms.1,2
"Concerns re: mood changes should not be a reason to deny either DMPA or Norplant to otherwise appropriate candidates," explains Andrew Kaunitz, MD, professor and assistant chair of the department of OB/GYN at the University of Florida Health Sciences Center in Jacksonville. "Both of these highly effective methods are appropriate for women with a history of depression, including those actively being treated, on or off medication."
While the results are not surprising, the reports do offer further information for use in counseling those patients with diagnosed depression as well as those who may be concerned about developing depressive symptoms, in choosing an appropriate contraceptive, notes Anita Nelson, MD, medical director of the Women’s Health Care Clinic, Harbor-University of California at Los Angeles Medical Center in Torrance.
Women with depression, who may be overwhelmed and having trouble coping with daily life tasks, may benefit the most from the two long-term, low-maintenance birth control methods, says Carolyn Westhoff, MD, MSc, medical director of family planning at Columbia Presbyterian Medical Center and associate professor of clinical OB/GYN and public health at Columbia Univer sity, both in New York City.
Westhoff and researchers at Columbia Pres-by terian Medical Center in New York City, Magee-Women’s Hospital in Pittsburgh, and the Uni ver sity of Texas Southwest Medical Center in Dallas designed a large prospective study to examine the determinants of contra ceptive choice. Analyses of depressive symptoms and use of DMPA and Norplant were derived from this study.
Women and depression
Depressive symptoms are found in many women in the United States, with a lifetime rate of major depression reported at 7.4/100 women, and the annual rate for depressive episodes for both men and women estimated at 3.0/100 persons.3
Some women experience depression when they use progestin-only contraceptives, note the authors of Contraceptive Technology.4 The product labeling for DMPA lists depression as an infrequent side effect, while Norplant’s labeling notes it as a rare side effect.
Westhoff and researchers at Columbia Univer sity looked at depression and use of DMPA and Norplant in earlier, smaller studies.5,6 Although the studies showed no evidence of a link between depressive symptoms and method use, concerns continued to be voiced about use of the progestin-only methods in women with or at risk for depression, she says.
Assessment is a key tool
Women were enrolled in the study through the family planning clinics at the three urban medical centers. The 910 women who chose Norplant were interviewed at enrollment, at six months, and at 24 months, while the 495 patients who selected DMPA were interviewed at enrollment and again at 12 months.
Included in the initial and follow-up questions were six questions from the Mental Health Inventory concerning depressive symptoms during the past month. Additional information was gathered concerning other factors related to depressive symptoms. Average age of participants was 23 years, with 50% at or below age 22.
Of the 910 who chose Norplant, 820 completed six-month follow-up interviews, with 727 continuing with the method and 93 reporting discontinued use. At the two-year follow-up, 81% who had been using Norplant at six months were re-interviewed. A total of 293 women were still using the method, and 295 had discontinued it. A total of 393 women on DMPA completed 12-month follow-up interviews, with 172 still using the method and 221 no longer receiving injections.
Women who continued either method had lower scores at baseline than did the women who discontinued the method or who were lost to follow-up. Those with the highest depressive symptom scores at enrollment demonstrated improved scores during follow-up.
Researchers were especially interested in looking at the 20% of patients who scored highest on the depressive symptom scale prior to starting the progestin-only methods, since this group would be the most likely to contain the women who were clinically depressed, Westhoff says. This quintile showed improved scores at follow-up, she notes.
A high depressive symptom score is not the same thing as clinical depression, she says. Women with depression probably will have a high score, and women with a high score have a heightened probability of depression over those with a low score, but the score is not the same thing as a clinical diagnosis, she points out.
"The fact that when groups of women are studied, and depression symptoms improve when they use DMPA, Norplant, and combined pills, does not preclude the possibility that depression may improve or become worse in an individual woman," warns Robert A. Hatcher, MD, MPH, professor of OB/GYN at Emory University in Atlanta. "Certainly depression should not be considered a reason to avoid these hormonal contraceptives."
These findings do not rule out the occurrence of rare or idiosyncratic mood changes in DMPA and Norplant users, says Westhoff. Because mood disorders are prevalent in young women, it is expected that some users of Norplant, DMPA, or any other birth control method, will develop depressive symptoms.
Based on anecdotal experience, some women may be predisposed to progestin-induced mood changes, Kaunitz says. Large, high-quality studies such as the two analyses described in this article have not been able to demonstrate clinical significance, he notes.
References
1. Westhoff C, Truman C, Kalmuss D, et al. Depressive symptoms and Norplant contraceptive implants. Contra ception 1998; 57:241-245.
2. Westhoff C, Truman C, Kalmuss D, et al. Depressive symptoms and Depo-Provera. Contraception 1998; 57:237-240.
3. Weissman MM, Bland RC, Canino GJ, et al. Cross-national epidemiology of major depression and bipolar disorder. JAMA 1996; 276:293-299.
4. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th ed. New York, NY: Ardent Media; 1998.
5. Gerber S, Westhoff C, Lopez M, et al. Use of Norplant implants in a New York City clinic population. Contraception 1994; 49:557-564.
6. Westhoff C, Wieland D, Tiezzi L. Depression in users of depo-medroxyprogesterone acetate. Contraception 1995; 51:351-354.
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