July 25, 2013 —Summary of "Young Women's Consistency of Contraceptive Use -- Does Depression or Stress Matter?" Stidham Hall et al., Contraception, June 2013.
More than half of the 3.1 million unintended pregnancies in the U.S. each year are among contraceptive users, with 90% of the pregnancies "attributed to non-, inconsistent or incorrect use of contraceptive methods," according to Kelli Stidham Hall of the University of Michigan's Institute for Social Research and colleagues. The researchers noted that many factors, such as demographic and relationship characteristics, have been shown to predict contraceptive misuse.
However, it is not known how mental health symptoms might affect contraceptive use, even though "[d]epression, anxiety and related psychological stress are common among young women and are known to impact health behaviors including prescription medication adherence" and sexual behavior, the researchers wrote.
Hall and colleagues designed a study to investigate "the influence of depression and stress on young women's weekly consistency of contraceptive use, overall and by contraceptive method."
The researchers interviewed 992 women ages 18 through 20 about their sociodemographics, relationship characteristics, reproductive attitudes, beliefs and intentions, contraceptive histories, and mental health symptoms. Ninety-nine percent of the women in the initial sample reported that they were not trying or planning to become pregnant.
The women were then asked to participate in a weekly journal-based study -- completed online or by phone -- that "assessed contraceptive use patterns, relationship status and pregnancy outcomes for a period of 2.5 years."
The final analytic sample covered the first 12 months of the study and included 689 women who completed 8,877 weekly journals.
The researchers measured depression and stress as "unique, individual determinants of contraceptive use." They noted that while depression and stress often are highly correlated, for purposes of the study, depression symptoms "reflect feelings of sadness or despair," while stress symptoms "reflect a psychological and emotional response to situational events."
The researchers used a screening tool known as the Center for Epidemiologic Studies -- Depression Scale-5, which measures depressive symptoms over the previous week, as well as a widely used stress screening method called the Perceived Stress Scale.
Each week, the researchers also asked the participants if they had been sexually active the week before. If so, the women were asked whether they had used any contraceptive methods, including "non-coital methods" -- such as oral contraceptives, patches, injectables or implants -- or "coital-specific methods" -- including condoms, withdrawal or emergency contraception. Women's responses were categorized in one of six specific method categories: long-acting methods, oral contraceptives, contraceptive ring or patch, condoms, other coital methods and withdrawal.
The researchers also asked whether women had used a contraceptive method at every act of sexual intercourse during the previous week, regardless if they were trying to prevent pregnancy. Contraceptive consistency was defined as "use of any contraceptive method (either a previously mentioned method or other type of method) at the time of every act of intercourse since the previous week's journal."
In addition, Hall and colleagues asked the participants a number of questions about various "relationship, reproductive and sociodemographic characteristics" each week, such as their relationship status, pregnancy status, employment status and frequency of religious service attendance.
The researchers then estimated associations between the "proportions of weeks of consistent contraceptive use and sociodemographic characteristics," as well as the "proportions of weeks of consistent contraceptive use and baseline mental health symptoms."
Contraceptive non-use was reported in 10% of study weeks, while non-coital methods were used in 48% of weeks and coital methods alone were used in 42% of weeks. In the weeks that contraception was used, few women reported using various long-acting methods such as injectables (6%), intrauterine devices (less than 1%) and implants (less than 1%). Larger proportions of women used oral contraceptives (44%), condoms (27%) or withdrawal (17%).
Overall, consistent contraceptive use was reported in 72% of weeks. In the other 28% of weeks, the most common inconsistently used contraceptive methods were withdrawal (38%), condoms (16%) and oral contraceptives (8%). The most common reasons for inconsistent use included "forgot" (31%), "did not have method available" (21%), "not happy with the method" (6%) and "partner did not want to use method" (6%).
The researchers also found that 27% of women at baseline met criteria for moderate to severe depression, while 25% met criteria for moderate to severe stress symptoms. The depression and stress symptoms were correlated, with 62% of women who expressed depression symptoms also expressing stress symptoms. Depression symptoms were associated with sociodemographic, sexual and reproductive characteristics, while stress symptoms were associated with sexual history. Women exhibiting depression or stress symptoms completed fewer journals than women without such symptoms.
The study determined that the proportion of consistent contraceptive weeks was 10 percentage points to 15 percentage points lower among women with depression and stress symptoms, respectively, than among women without such symptoms. Specifically, depressed women had a 47% lower likelihood of contraceptive consistency each week, while stressed women had 69% lower odds of contraceptive consistency.
"We found that while sexually active young women reported using a contraceptive method in 90% of study weeks, a method was not used with every act of intercourse just over one-quarter of the time," the researchers wrote, noting that inconsistent contraceptive use was most frequently reported "for the most commonly used methods, which have effectiveness highly dependent upon user characteristics and behaviors."
The researchers also explained that the study "addresses gaps in previous research by using a population-based sample and repeated measures design[ed] to identify an association between depression and stress and weekly inconsistent contraceptive use over a one year period." They noted that "depression and stress in [the] sample were highly correlated but distinct constructs, with stress exhibiting the most consistently negative association with contraceptive use, overall and across method types."
Conclusions and Implications
The study demonstrated "that young women with elevated depression and stress symptoms appear to be at risk for inconsistent contraceptive use patterns, especially for the most common methods that require greater user effort and diligence," Hall and colleagues wrote. They recommended that clinicians assess and address "women's psychological and emotional status when helping patients with contraceptive decision-making and management."
The researchers added, "Women with stress or depression may be ideal candidates for long-acting reversible methods, which offer highly effective options with less user-related adherence concerns." They recommended that future research examine "how young women's dynamic mental health symptoms impact family planned behaviors and outcomes over time."