Suicide Risk | the Role of Hormonal Contraception and Risk

Suicide is still difficult to predict, and is a common cause of death, resulting in over 40,000 deaths a year.

Suicide is rising in younger age groups, as is self-harm or non-suicidal self injury (NSSI) which can result in unintended fatality.

The factors affecting young men and women are different, and also overlap. Understanding the risk factors combined with careful assessment and clinical decision-making is the standard of care at this time, though in the future we may have neuroscience-based techniques to provide more objective and reliable assessment. In the meantime, researchers continue to identify relevant risk factors, which clinicians and patients include in treatment planning, especially when there is concern about suicide and self-injury.

In order to investigate the role of hormonal contraception on suicide-related factors, Skovlund and colleagues (2017) analyzed population data to look for patterns in contraception use and suicide risk factors. They note that hormonal treatments are used by 100 million women around the world for purposes ranging from contraception, to relief of menstrual symptoms such as pain and bleeding, and premenstrual syndrome.

Hormonal contraception has been associated in previous studies with depression and negative effects on mood, and has also been show to increase the risk of suicide and suicide attempts in multiple studies (Skovlund et al., 2016; Schaffir et al., 2016; Bertolote et al., 2003).

Prior research with large cohorts have been mixed, with some studies showing no elevated risk related to suicide, and others showing a significant increase in risk. In addition, hormonal contraception has been associated with risk for some diseases, including some forms of cancer and problems with blood clotting too easily.

• The benefits of any treatments must outweigh the potential costs in order to justify their use, a calculation often difficult for a variety of reasons to make accurately. In order to provide clarity and detail to our understanding, Skovlund and colleagues conducted additional research.

They looked at data from the Danish Sex Hormone Register Study, which includes all women living living in Denmark, the National Prescription Register to cross-reference with hormonal contraceptives and psychiatric medications, the Psychiatric Central Research Register to include psychiatric diagnoses and outcomes, the Cause of Death Register for suicide, and the National Health Register for data on suicide attempts and diagnosis of cancer and thrombosis.

They looked at data from 475,802 women in the registers from 1996-2003, adding up to 3,920,818 person-years. The average age of subjects was 21 years, and 54% had current or recent use of hormonal contraception. During the follow-up period, there were 6,999 suicide attempts and 71 completed suicides.

They found that those who had used hormonal contraception has a 1.97 higher risk (relative risk) for a first suicide attempt, and 3.08 higher risk for completing suicide. By age group, the relative risks were as follows: 2.06 fold increase in 15-19 year olds; 1.61 fold increase in 20-24 year olds; 1.64 fold increase in 25-33 year olds.

In addition, the risk of a first suicide attempt at least doubled right away upon starting hormonal contraception, and remained elevated for one year. After that, risk declined but remained at least 30 percent higher for over 7 years, compared with those who had never used hormonal contraception. Former users had a relative risk of 3.4 for a first attempt, and a relative risk of 4.82 for suicide completion. Progestin-only hormonal contraceptives were associated with an elevated relative risk, of 2.29 compared with products combining estrogen compounds with progesterone.

The overall risk with hormonal contraception use, after adjusting for psychiatric diagnosis and antidepressant use, was 1.58. Psychiatric diagnosis and antidepressant use accounted for 1.25 relative risk, and 33 percent of the risk was considered to be related to unknown interactions between contraceptive use status and psychiatric factors, including family history of suicide.

• Risk was higher in younger women, and higher for those using progesterone-only contraception. Risk was higher in the first year, and tapered off.

For any woman, and notably those with associated risk factors including age, how long they've been using contraception, type of contraception, and psychiatric risk, it is important to look at the risk from hormonal contraception on suicidality. If suicidal thinking is present, it may be useful (with proper medical oversight) to consider modification of hormonal contraception to see if this reduces suicidality, and to provide a higher level of vigilance when risk factors are present.

It may be wiser to choose lower risk contraceptive approaches if other significant risks of suicide are already present. Understanding how different hormonal contraceptives lead to increased suicide risk may improve our understanding of how endocrinefactors related to depression and other psychiatric conditions, as well as offer better assessment and therapeutic tools to make well-informed, personalized treatment recommendations.

Further research is required to better understand how hormonal contraception may affect suicide and health risks in different groups.

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