Association of Hormonal Contraceptive Use With Reduced Levels of Depressive Symptoms

A National Study of Sexually Active Women in the United States

Katherine M. Keyes; Keely Cheslack-Postava; Carolyn Westhoff; Christine M. Heim; Michelle Haloossim; Kate Walsh; Karestan Koenen


Am J Epidemiol. 2013;178(9):1378-1388. 

In This Article

Abstract and Introduction


An estimated 80% of sexually active young women in the United States use hormonal contraceptives during their reproductive years. Associations between hormonal contraceptive use and mood disturbances remain understudied, despite the hypothesis that estrogen and progesterone play a role in mood problems. In this study, we used data from 6,654 sexually active nonpregnant women across 4 waves of the National Longitudinal Study of Adolescent Health (1994–2008), focusing on women aged 25–34 years. Women were asked about hormonal contraceptive use in the context of a current sexual partnership; thus, contraceptive users were compared with other sexually active women who were using either nonhormonal contraception or no contraception. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale. At ages 25–34 years, hormonal contraceptive users had lower mean levels of concurrent depressive symptoms (β = −1.04, 95% confidence interval: −1.73, −0.35) and were less likely to report a past-year suicide attempt (odds ratio = 0.37, 95% confidence interval: 0.14, 0.95) than women using low-efficacy contraception or no contraception, in models adjusted for propensity scores for hormonal contraceptive use. Longitudinal analyses indicated that associations between hormonal contraception and depressive symptoms were stable. Hormonal contraception may reduce levels of depressive symptoms among young women. Systematic investigation of exogenous hormones as a potential preventive factor in psychiatric epidemiology is warranted.


An estimated 80% of sexually active women in the United States use hormonal contraception, most typically oral contraceptives, to prevent pregnancy.[1] In addition to providing effective pregnancy prevention, hormonal contraception offers many health benefits,[2–4] though its use remains a risk factor for venous thromboembolism and other vascular disease outcomes.[5]

Little research has focused on the association of hormonal contraceptive use with mental health outcomes, such as depressive symptoms, and more severe manifestations of mood disturbance, such as suicide attempts. Approximately 17% of women experience major depression during their lifetime, with incidence being highest during the reproductive years,[6] and many more experience depressive symptoms that do not necessarily cross the threshold to a diagnosis but may be disabling.[7,8] While a role for hormones such as estrogen and progesterone in the etiology of depressive symptoms has been hypothesized,[9–11] the association remains inadequately understood. Clinical studies have indicated that precipitous changes in estrogen levels may trigger depressive episodes among women at risk for depression, particularly during the late luteal phase of the menstrual cycle and during postpartum and perimenopausal periods,[12,13] and that women with major depression generally have lower estradiol levels than controls.[14,15] Given that hormonal contraception methods introduce synthetic estrogen and progestin and modulate the physiological cycle, an examination of the role of hormonal contraception in mood problems is warranted.

Few population-based studies have evaluated the association between hormonal contraceptive use and depressive symptoms. Among 3 population-based studies conducted within the last 15 years, 2 found no consistent evidence of an association (positive or negative) between hormonal contraceptive use and depressive symptoms,[16,17] while a recent population-based study in Finland found that hormonal contraceptive use reduced levels of depressive symptoms.[18] A recent study of long-term mortality based on oral contraceptive use found an increase in violent deaths, including suicide, among oral contraceptive users compared with nonusers,[19] although 2 other large studies found no increase in suicide risk for oral contraceptive use.[20,21] To our knowledge, no studies have examined oral contraceptive use in relation to suicide attempts, which are more common and have different risk factors than completed suicide.[22] Thus, there remains limited evidence regarding potential associations between hormonal contraceptive use and depressive symptoms or suicidality, despite widespread use of these methods for pregnancy prevention and other outcomes.

In the present study, we utilized data from a nationally representative US longitudinal study to investigate the association between contraceptive use and depressive symptoms, as well as suicide attempts. First, we compared women who were using various forms of hormonal and nonhormonal contraception with women who were using no contraception with regard to various dimensions of health, including exercise, body mass index, smoking, and engagement with health professionals. Second, we tested the association between contraceptive use and concurrent depressive symptoms, as well as past-year suicide attempts, while controlling for health-related dimensions that varied across contraceptive users. We used traditional adjustment as well as propensity score adjustment to control for sources of confounding. Lastly, we examined longitudinally whether hormonal contraceptive use predicted depressive symptoms/suicide attempts and whether depressive symptoms/suicide attempts predicted hormonal contraceptive use.