Population-based cohort study of oral contraceptive use and risk of depression

Abstract

Aim: Research on the effect of oral contraceptive (OC) use on the risk of depression shows inconsistent findings, especially in adult OC users. One possible reason for this inconsistency is the omission of women who discontinue OCs due to adverse mood effects, leading to healthy user bias. To address this issue, we aim to estimate the risk of depression that is associated with the initiation of OCs as well as the effect of OC use on lifetime risk of depression.

Methods: This is a population-based cohort study based on data from 264,557 women from the UK Biobank. Incidence of depression was addressed via interviews, inpatient hospital or primary care data. The hazard ratio (HR) between OC use and incident depression was estimated by multivariable Cox regression with OC use as a time-varying exposure. To validate causality, we examined familial confounding in 7,354 sibling pairs.

Results: We observed that the first 2 years of OC use were associated with a higher rate of depression compared to never users (HR = 1.71, 95% confidence interval [CI]: 1.55-1.88). Although the risk was not as pronounced beyond the first 2 years, ever OC use was still associated with an increased lifetime risk of depression (HR = 1.05, 95% CI: 1.01-1.09). Previous OC use were associated with a higher rate of depression compared to never users, with adolescent OC users driving the increased hazard (HR = 1.18, 95% CI: 1.12-1.25). No significant association were observed among adult OC users who had previously used OCs (HR = 1.00, 95% CI: 0.95-1.04). Notably, the sibling analysis provided further evidence for a causal effect of OC use on the risk of depression.

Conclusions: Our findings suggest that the use of OCs, particularly during the first 2 years, increases the risk of depression. Additionally, OC use during adolescence might increase the risk of depression later in life. Our results are consistent with a causal relationship between OC use and depression, as supported by the sibling analysis. This study highlights the importance of considering the healthy user bias as well as family-level confounding in studies of OC use and mental health outcomes. Physicians and patients should be aware of this potential risk when considering OCs, and individualized risk-benefit assessments should be conducted.

Keywords: depression; epidemiology; mental health; women.

Figure 1.

Year of initiating oral contraceptive use. The histogram shows the number of women who first initiated oral contraceptive use each year. The numbers are based on the 205,858 women in the UK Biobank who reported their age at the time of initiation. The year at initiation has been calculated using information on year of birth.

Figure 2.

Short-term and lifetime HR of initiation of oral contraceptive use on depression. All estimates are adjusted for year of birth, TDI (used as proxy for socioeconomic status), number of live births, number of still births, PCOS (defined as having ICD10 code E28), age at menarche, age at sexual debut and family history of severe depression (defined as having one or more first-degree relatives with depression). Adolescents are defined as women who initiated oral contraceptives either before or at the age of 20, while adults are defined as women initiating oral contraceptives after turning 20 years old. Lifetime risk = among all women who initiated oral contraceptives at some time point during the follow-up. *Secondary outcome measurement on the subcohort of women (N = 82,232) who answered in mental health questionnaire.

Figure 3.

Time-dependent HR of oral contraceptive use and depression. All estimates are adjusted for year of birth, TDI (used as proxy for socioeconomic status), number of live births, number of still births, PCOS (defined as having ICD10 code E28), age at menarche, age at sexual debut and family history of severe depression (defined as having one or more first-degree relatives with depression). *Recent users defined as those who discontinued within 2 years. *Secondary outcome measurement on the subcohort of women (N = 82,232) who answered the mental health questionnaire. **Parous women were followed until 1 year before delivery.