According to the World Health Organization (WHO), the number of women using modern contraceptive methods has increased from 663 million in 2000 to 851 million in 2020, with an additional 70 million projected to initiate contraception by 2030.1 Women now have multiple contraceptive options that can be tailored to individual needs and preferences, such as combined oral contraceptives (COCs), progestogen-only pills (POPs), injectables, combined contraceptive patches, intrauterine devices (IUDs), and implants.2 In the United States, oral contraceptive pills are the most commonly used method, accounting for 21.9% of current contraceptive use.2 Barriers to contraception use include limited health care access, cultural or religious objections, restricted choice of methods, gender-based barriers to care, and financial constraints.1Â
Contraceptive methods are broadly categorized as hormonal and nonhormonal (Table).1-4 Nonhormonal options include condoms, diaphragms, and copper IUDs. Hormonal contraceptives use progestin with or without estrogen. Progestin, a synthetic analogue of progesterone, suppresses gonadotropin-releasing hormone from the hypothalamus, thereby reducing pituitary luteinizing hormone and preventing ovulation.2 Progestin also thickens cervical mucus and decreases sperm motility and survival. Estrogen-containing methods further enhance contraceptive effectiveness by suppressing gonadotropins and follicle-stimulating hormone (FSH) and by reducing irregular bleeding.2 Each method has a distinct profile of adverse effects. Patients also often use contraceptives for additional indications, such as dysmenorrhea, acne, heavy menstrual bleeding, or premenstrual symptoms. Certain contraceptives also reduce the risk for ovarian, endometrial, and colorectal cancers.3
Table 1. Comparison of Contraception MethodsÂ
CategoryMethodMechanism HormonalCombined oral contraceptivesPrevent ovulationProgestogen-only pillsThicken cervical mucus and prevent ovulationProgestogen-only injectables Thicken cervical mucus and prevent ovulationCombined injectablesPrevent ovulation Combined contraceptive patchesPrevent ovulation Combined contraceptive vaginal ringsPrevent ovulationImplantsThicken cervical mucus and prevent ovulationNonhormonalCopper intrauterine devicesCreate an inflammatory response that is toxic to sperm and eggs Condoms Form barrier to prevent sperm from meeting eggs DiaphragmsForm barrier to prevent sperm from meeting eggsBased on references 1-4.
Mental Health Effects of ContraceptionÂ
Women may experience emotional fluctuation across the menstrual cycle, reflecting complex neuroendocrine changes.3 A key pathway involved is the gamma-aminobutyric acid (GABA) system, which is sensitive to progesterone and its neuroactive metabolites (neurosteroids).3 Specifically, the neurosteroid allopregnanolone, which fluctuates with progesterone levels, exerts anxiolytic and anticonvulsant effects via GABAergic modulation.3 Cyclic changes in allopregnanolone and related neurosteroids are thought to contribute to the spectrum of affective and somatic symptoms across the menstrual cycle.Â
Because hormonal contraceptives alter endogenous hormone levels and neurochemical pathways, ongoing research has focused on whether their use is associated with depression or other mental health outcomes.5-10Â
Depression With Hormonal Contraceptive Use
Globally, an estimated 5% of adults have depression, and women experience approximately a 50% higher incidence of depression than men.11 Depressive episodes are characterized by persistent low mood, irritability, and emptiness or diminished interest or pleasure, occurring most of the day, nearly every day, for at least 2 weeks.12 These symptoms impair occupational functioning, interpersonal relationships, and daily activities.11,12Â
A 2024 systematic review and meta-analysis by Kraft et al evaluated correlations between oral contraceptive (OC) use and mental disorders by analyzing 22 studies from 2000 to 2022, encompassing 10,642,840 observations.5 Fifteen studies analyzed found no significant association between OC use and mental disorders. Three studies found a positive effect of OC use on mental health, with lower reported rates of phobia, anxiety, and paranoid ideation. Three studies reported a significant association between OC use and depression, particularly suggesting that adolescent OC use may be linked to higher rates of depression in adulthood.5-7 Overall, Kraft et al concluded that a clinically meaningful relationship between OC use and mental health disorders in the general population is unlikely, although potential effects in specific populations, such as adolescents, warrant attention.5
A cohort study by Edwards et al in 2022 used Swedish national registry data and Cox proportional hazard models to evaluate correlations between hormonal contraceptive use and suicidal behavior. Crude analyses found a positive association between the use of combined or progestin-only contraception and suicidal behavior, with the highest risk in the first month after initiation.8 After adjusting for sociodemographic, parental, and psychiatric factors, women using hormonal contraceptives had a 50% to 113% increased likelihood of suicidal behavior during the first month compared with nonusers (hazard ratio [HR], 1.56-2.13).8 After 1 year of continued use, this decreased to a 19% to 48% increased likelihood (HR, 1.19-1.48). Hazard ratios were higher among the women who discontinued hormonal contraception during follow-up, suggesting that individuals who are more vulnerable may be more likely to stop treatment.8Â
In a 2021 community-based cross-sectional study conducted in Saudi Arabia by Albawardi et al evaluated women aged 21 to 45 years using hormonal or nonhormonal contraception who had no prior history of depression.10 The study used the Patient Health Questionnaire-9 to screen for depression. Compared with women using nonhormonal methods, those taking hormonal contraceptives had higher risk for moderate to severe depression (odds ratio, 1.276; P=0.00).10 This study was limited by its observational design but suggested an association between hormonal contraceptive use—mainly combined estrogen–progestin pills—and moderate to severe depression.10Â
A population-based cohort study by Johansson et al, using UK Biobank data, found an increased rate of depression during the first 2 years of OC vs no use of OCs.9 After the initial 2-year period, the relative risk attenuated, but women who had ever used OCs still demonstrated a higher lifetime risk for depression than those who had never used OCs.9Â
Collectively, current evidence suggests that although large, high-quality analyses do not support a strong overall association between OC use and depression in the general population, a subset of women—particularly adolescents and possibly early users—may be more susceptible to mood changes.5-10 (Table 2)
Table 2. Summary of Key Research Findings of Depression and Oral Contraceptives
StudyPopulationKey FindingKraft et al510.6 million observationsNo clinically meaningful link in the general population; potential risk in adolescents.Edwards et al8Swedish RegistryWomen who used hormonal contraceptives had 50%–113% increased likelihood for suicidal behavior in the first month of use compared with non-users.Johansson et al9 UK BiobankIncreased risk of depression during the first 2 years of OC use compared to non-users.Albawardi et al10Saudi ArabiaHigher risk for moderate to severe depression in women taking hormonal vs. nonhormonal users. Based on references 5, 8-10.
Special Considerations in AdolescentsÂ
Adolescence, typically defined as ages 10 to 19 years, is a period of substantial physiologic, neurobiologic, and psychosocial change.13 During this time, key emotional-processing centers, such as the amygdala, prefrontal cortex, and hippocampus, are still maturing and may be particularly sensitive to sex-hormone–related changes.6,14 This heightened sensitivity may increase vulnerability to mood disturbances in adolescents who use hormonal contraception.6
A population-based cohort study by Johansson et al found that both adolescents and women older than 20 years had an increased risk for depression with OC use, and that women who initiated OCs during adolescence remained at heightened risk for depression even after discontinuation, a pattern not seen in adult initiators.9 Several studies have hypothesized that adolescent exposure to exogenous hormones may affect the organization and development of brain structures during this critical period, potentially leading to persistent effects on mood regulation.6,9,14 Further research is necessary to fully clarify these mechanisms.
Anderl et al conducted a large prospective study using data from the Dutch TRAILS (Tracking Adolescents’ Individual Life Survey) cohort to examine whether adolescent OC use predicts later episodes of major depressive disorder (MDD).6 Participants were enrolled at 11 years old and followed through adolescence, with contraceptive use assessed at ages 13, 16, and 19 years and MDD evaluated at age 25 using the Lifetime Depression Assessment Self-Report (LIDAS), which incorporates all 9 diagnostic criteria for MDD from the Diagnostic and Statistical Manual of Mental Disorders-IV. OC use was associated with an increased risk for MDD up to 6 years later, with the greatest risk found in participants without prior depressive episodes (OR, 1.41).6 This increased risk was not observed in participants with a history of MDD by age 19, suggesting that OC use did not further increase risk in those with preexisting depression.6
In a Danish population-based study, McCloskey et al reported that OC users had an increased risk for initiating antidepressant medications, with risk peaking approximately 6Â months after starting OCs and then declining.15 The association was strongest among adolescents aged 15 to 19 years and was greater for progestin-only pills (relative risk [RR], 2.2; 95% confidence interval [CI], 1.99-2.52) than with combined oral contraceptives (RR, 1.8; 95% CI,1.75-1.84).15
Taken together, these studies suggest that adolescents who use hormonal contraception may be at increased risk for depression, particularly during the months to years of use, and that this risk may persist beyond discontinuation in some individuals.9.15 Clinically, adolescents starting hormonal contraceptives warrant close follow-up and routine screening for depressive symptoms. (Table 3)
Table 3. Summary of Key Research Findings: Adolescent Hormonal Contraception
StudyPopulationKey FindingsJohansson et al9UK BiobankIncreased depression risk during oral contraceptive use; adolescent initiators remained at higher risk even after discontinuation.Anderl et al6Dutch TRAILS cohort (followed to age 25)OC use predicted major depressive disorder up to 6 years later; highest risk in those with no prior depressive episodes (OR, 1.41).McCloskey et al15Danish population-based studyIncreased antidepressant initiation peaking at 6 months; risk was higher for progestin-only pills (RR, 2.2) than combined oral contraceptives (RR, 1.8).Based on references 6,9,15.
Contraception for Patients With Prior Psychiatric DiagnosesÂ
When considering contraceptive options for patients with existing psychiatric conditions, providers must integrate mental health history, current treatment, and reproductive goals into shared decision making. Psychiatric disorders are multifactorial, and interactions among environmental, genetic, lifestyle, and hormonal factors produce substantial interindividual variability in response to hormonal contraceptives.3
Both adolescents and women older than 20 years had an increased risk for depression with oral contraceptive use, and women who initiated OCs during adolescence remained at heightened risk for depression even after discontinuation.
In an analysis of data from the Sequenced Treatment Alternative to Relieve Depression (STARD) study, McCloskey et al found that women using combined hormonal contraceptives had less severe depressive and anxiety symptoms, better physical functioning, and no evidence of mood destabilization compared with nonusers in certain cohorts.15 In addition, the use of OCs, levonorgestrel-releasing IUDs, and depot medroxyprogesterone acetate injections in women with bipolar disorder or depression did not result in worse psychiatric outcomes than use of nonhormonal contraception.15 Other studies, however, have reported that women with a history of mental health disorders may be more likely to experience mood symptoms with COCs.3Â
A study by Lundin et al on the mental health effects of attention-deficit hyperactivity disorder (ADHD) found that women with ADHD have a 3-fold higher risk for developing depression than those without ADHD, independent of contraception use.16 Among women with ADHD who used hormonal contraception, depression risk was approximately 6-fold higher than in contraceptive users without ADHD. These findings underscore the importance of discussing baseline risks and potential additive risks in patients who have ADHD or other psychiatric diagnoses.
Overall, available data do not support a consistent worsening of psychiatric symptoms attributable to hormonal contraceptives in women with established psychiatric disorders.3,15 Nonetheless, careful monitoring and individualized counseling are essential, particularly in patients with complex psychiatric histories or multiple risk factors.
Many women with psychiatric disorders also have comorbid medical conditions and take multiple medications, which may influence contraceptive selection. For example, estrogen-containing methods increase the risk for thromboembolic and cardiovascular events in women who smoke and have hypertension; in such patients, progestin-only or long-acting reversible contraceptives are generally preferred.15 Providers should consider the full clinical context to provide holistic, patient-centered contraceptive care.Â
Methodological Challenges and BiasÂ
Research on hormonal contraceptives and mental health is methodologically challenging. Many studies focus exclusively on COCs or group multiple hormonal methods together without stratified analyses, limiting conclusions about specific formulations.17 Healthy user bias is another concern, as women who experience significant mood-related adverse effects may discontinue hormonal contraception and thus be underrepresented among current users in observational cohorts.9 In addition, most studies are observational, making it difficult to fully adjust for confounders such as baseline mental health, life stressors, and socioeconomic factors.
To more definitively assess causal relationships between hormonal contraceptive use and mental health outcomes, long-term, prospective studies of first-time users, ideally with randomized or quasi-experimental designs, are needed.6 Careful attention to baseline mental health, standardized outcome measures, and differentiation among contraceptive types and doses will be critical.
ConclusionÂ
Patients should be counseled about potential mental health effects of hormonal contraceptives before initiation and should receive ongoing follow-up during use. Given evidence that some users—particularly adolescents—may have an increased risk for depression, routine screening for mood symptoms by gynecology and primary care providers is warranted, especially in the first months after starting hormonal contraception.15Â
Large meta-analyses do not demonstrate a robust, generalizable increase in depression risk with OC use in the overall population, but they highlight possible elevated risk in specific subgroups, such as adolescents and individuals with certain vulnerabilities.5 In adolescent populations, careful evaluation for depressive symptoms after the initiation of contraceptives and continued monitoring over time are particularly important.Â
Ultimately, providing holistic contraceptive counseling that includes discussions of mental health is essential. Clinicians should integrate patients’ psychiatric history, current symptoms, preferences, and life context when recommending contraceptive methods. With thoughtful, individualized care and appropriate monitoring, most women, including those with psychiatric comorbidities, can safely use hormonal contraceptives while minimizing mental health risks.