Skovlund, C. W., Mørch, L. S., Kessing, L. V., Lange, T., & Lidegaard, Ø. (2018). Association of Hormonal Contraception With Suicide Attempts and Suicides. The American Journal of Psychiatry, 175(4), 336-342. https://doi.org/10.1176/appi.ajp.2017.17060616
Skovlund CW, Mørch LS, Kessing LV, Lange T, Lidegaard Ø. Association of Hormonal Contraception With Suicide Attempts and Suicides. Am J Psychiatry. 2018;175(4):336-342. doi:10.1176/appi.ajp.2017.17060616
Skovlund, Charlotte Wessel, et al. "Association of Hormonal Contraception With Suicide Attempts and Suicides." The American Journal of Psychiatry, vol. 175, no. 4, 2018, pp. 336-342.
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Hormonal Contraception Linked to Higher Suicide Attempt Risk
Women using hormonal contraception had nearly double the risk of a first suicide attempt, a Danish registry study of 475,802 women found, with the risk highest among teenagers. Suicide itself was about three times more common among users than nonusers.
Key Findings
Current or recent users faced a 1.97-fold higher hazard of a first suicide attempt (95% CI=1.85-2.10) and a 3.08-fold higher hazard of suicide (95% CI=1.34-7.08), compared with nonusers.
Teenagers ages 15 to 19 carried the highest suicide-attempt hazard ratio, 2.06 (95% CI=1.92-2.21); 1.61 (95% CI=1.39-1.85) for ages 20 to 24; and 1.64 (95% CI=1.14-2.36) for ages 25 to 33.
Suicide-attempt hazard ratios were 1.91 (95% CI=1.79-2.03) for oral combined pills, 2.29 (95% CI=1.77-2.95) for progestin-only pills, 2.58 (95% CI=2.06-3.22) for the vaginal ring, and 3.28 (95% CI=2.08-5.16) for the patch.
The suicide-attempt hazard ratio peaked around 2 months after starting hormonal contraception, stayed doubled through the first year, then eased to about 30% above nonusers' risk after more than 7 years.
Former users showed a higher hazard still: 3.40-fold (95% CI=3.11-3.71) for a first suicide attempt, 4.82-fold (95% CI=1.93-12.1) for suicide. The authors attribute this to selection, women stopping after a mood-related reaction.
Interpretation
This is a Danish registry cohort that followed healthy girls from age 15 through 33, with no prior psychiatric history or contraceptive use. The women were tracked for an average of 8.3 years using government prescription and health records. The registry size let the authors detect rare outcomes like suicide and track risk over time. The hazard ratios are adjusted for measured factors. A bias analysis found that an unmeasured confounder would need unusually high strength and prevalence to explain the result. Adjusting for diagnosed psychiatric illness and antidepressant use lowered the suicide-attempt hazard ratio to 1.58 (95% CI=1.48-1.68), so most of the association remained unexplained by diagnosed mental illness.
RRM Context
Hormonal contraception is often used for menstrual pain, heavy bleeding, or acne. Restorative reproductive medicine looks for the underlying cause of these symptoms. The same authors earlier found a 70 percent higher rate of depression among users. Together, the suicide and depression findings suggest hormonal contraception can affect mood beyond pregnancy prevention.
Our editorial summary of this paper, not the article's abstract.
Abstract
Objective
The purpose of this study was to assess the relative risk of suicide attempt and suicide in users of hormonal contraception.
Method
The authors assessed associations between hormonal contraceptive use and suicide attempt and suicide in a nationwide prospective cohort study of all women in Denmark who had no psychiatric diagnoses, antidepressant use, or hormonal contraceptive use before age 15 and who turned 15 during the study period, which extended from 1996 through 2013. Nationwide registers provided individually updated information about use of hormonal contraception, suicide attempt, suicide, and potential confounding variables. Psychiatric diagnoses or antidepressant use during the study period were considered potential mediators between hormonal contraceptive use and risk of suicide attempt. Adjusted hazard ratios for suicide attempt and suicide were estimated for users of hormonal contraception as compared with those who never used hormonal contraception.
Results
Among nearly half a million women followed on average for 8.3 years (3.9 million person-years) with a mean age of 21 years, 6,999 first suicide attempts and 71 suicides were identified. Compared with women who never used hormonal contraceptives, the relative risk among current and recent users was 1.97 (95% CI=1.85–2.10) for suicide attempt and 3.08 (95% CI=1.34–7.08) for suicide. Risk estimates for suicide attempt were 1.91 (95% CI=1.79–2.03) for oral combined products, 2.29 (95% CI=1.77–2.95) for oral progestin-only products, 2.58 (95% CI=2.06–3.22) for vaginal ring, and 3.28 (95% CI=2.08–5.16) for patch. The association between hormonal contraceptive use and a first suicide attempt peaked after 2 months of use.
Conclusions
Use of hormonal contraception was positively associated with subsequent suicide attempt and suicide. Adolescent women experienced the highest relative risk.
