Arch Womens Ment Health (2009) 12:183–185 DOI 10.1007/s00737-009-0060-y
SHORT COMMUNICATION
Use of contraceptive methods among women treated for bipolar disorder Pedro Vieira da Silva Magalhães & Flávio Kapczinski & Marcia Kauer-Sant’Anna
Received: 11 October 2008 / Accepted: 11 February 2009 / Published online: 10 March 2009 # Springer-Verlag 2009
Abstract Contraception has been little investigated in bipolar disorder, an illness associated with impulsive sexual behavior and use of medications that are unsafe during pregnancy. In this cross-sectional survey of 136 women with bipolar disorder, prevalence of contraception use was 58.8%. Use of any method was associated in the multivariable analysis with being married, younger than 40 and having had previous pregnancies. Women diagnosed with bipolar disorder and treated in a tertiary facility use contraceptive methods suboptimally. Keywords Bipolar disorder . Contraception . Oral contraception . Condom . Women survey
Introduction Sex differences have been more widely explored in schizophrenia or major depression than in bipolar disorder (Curtis 2005). Use of contraception in women being treated for bipolar disorder is one especially relevant aspect of sexual health. Treatment usually entails use of medications that not only interfere with the clearance of oral contraceptives, but may also be teratogenic or unsafe, such as the anticonvulsant mood stabilizers or lithium (Cohen 2007).
Funding sources: this study was supported by FIPE-HCPA. P. Vieira da Silva Magalhães : F. Kapczinski (*) : M. Kauer-Sant’Anna Bipolar Disorders Program & Molecular Psychiatry Laboratory, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos, 2350, CEP 90035-003 Porto Alegre, RS, Brazil e-mail:
[email protected]
Untreated maternal mood disorders during pregnancy are serious risk factors for the fetus as well, posing significant management issues for the pregnancy of those with bipolar disorder; the postpartum period is also a high-risk time for relapse (Harlow et al. 2007). Clinicians have been urged to thoroughly discuss these risks with the patients (Curtis 2005). Another reason contraception is particularly relevant to those with bipolar illness is the association of mania with impulsivity and HIV risk behavior (Meade et al. 2008). An uninvestigated concern is that this behavior may lead to unplanned pregnancy and sexually transmitted diseases (McCandless and Sladen 2003). Outpatient samples of patients with bipolar disorder have indeed revealed much higher than expected rates of HIV infection (Beyer et al. 2007). Research on contraceptive use in patients with mood disorders is very limited (McCandless and Sladen 2003). Therefore, the aim of this report is to investigate, in a well characterized population of women with BD, the prevalence of contraception use, as well as examining demographic correlates of its use.
Methods Participants were consecutive outpatients enrolled in the Bipolar Disorders Program at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil, with a diagnosis confirmed with the Structured Clinical Interview for DSM-IV. Inclusion criteria are deliberately broad so as to capture the full range of patients, regardless of comorbidity. Subjects enrolled in the program received open label maintenance treatment for BD from clinicians with expertise in management of mood disorders.
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After excluding postmenopausal women (n=46), 141 patients were eligible for this study, and data regarding contraception was available for 96.5% (n=136) of the sample, which is the population included in this report. Participants gave written informed consent before entering the study, which was approved by the local ethics committee. Menopausal status was self-reported, as was use of contraception. Other clinical and demographical information was obtained with a standard form at study entry. The Young Mania Rating Scale (Vilela et al. 2004) and the Hamilton Depression Rating Scale (Fleck et al. 2004) were used to assess (hypo)manic and depressive symptoms, respectively. Chi-squared tests were employed to evaluate associations between categorical variables, and odds ratios (OR) and respective confidence intervals were generated. Oneway ANOVA with a Tukey correction for multiple comparisons was used for the analysis of age × method of choice. For this analysis, methods were grouped as: (1) none, (2) oral contraceptive, (3) condom, (4) permanent contraception (tubal ligation or partner vasectomy) or (5) other methods. For the logistic regression model, we dichotomized age with a cutoff of 40 years, both as pregnancy is less expected and there is evidence of differential use of contraceptive type in this age group (Carreno et al. 2006). The number of previous pregnancies was categorized as 0, one or two, and more than two, so as not to impede regressions because of too few patients per group. All tests are two-tailed.
P.V. da Silva Magalhães et al. Table 1 Sample demographic and clinical characteristics Characteristic Age Income Married/living with partner On disability/unemployed Years of Education On any contraceptive Oral contraception Tubal ligation
38 (15) 1000 (805) 41.1% 56.9% 11 (4) 58.8% 16.2% 16.3%
Partner vasectomy Intra-uterine device Condom Other Times pregnant None Once or twice More than twice Clinical Global Impression Hamilton Depression Rating Scale Young Mania Rating Scale Ever hospitalized Bipolar I disorder Currently using lithium Currently using anticonvulsants Number of medications used for bipolar disorder
2.8% 4.4% 12.8% 9.6% 22.1% 44.9% 33.0% 4 (2) 9 (10) 4 (8) 75% 86.7% 58.5% 74.3% 3 (1)
Continuous data shown as median (interquartile range)
Results We were able to include 136 patients for this report (see Table 1 for sample characteristics). In the bivariate analysis, use of any contraceptive method was more frequent in those married or living with a partner (OR=2.87, 95%CI 1.38–6.00), younger age group (OR=2.10, 95%CI 1.05– 4.23) and a linear-to-linear association emerged with number of pregnancies (χ=4.88, p=0.03); it was unrelated to income (F=0.762, p=0.385) or years of education (F= 0.002, p=0.962). No associations were found with symptoms or illness severity (p>0.45 for all). Use of lithium and anticonvulsant mood stabilizers was unrelated to use of contraception, and a considerable fraction of patients on these medications did not use any method (39.6% and 41%, respectively). In the logistic regression model, being married (OR= 2.41, 95%CI 1.07–5.46, p=0.034), pertaining to the older age group (OR=3.94, 95%CI 1.65–9.42, p=0.002) and having had one or two pregnancies (OR=3.96, 95%CI 1.20–13.11, p=0.024) and more than two (OR=2.73, 95% CI 1.02–7.31, p=0.046) remained associated with using contraception.
In the analysis with women classified by method of choice, those using oral contraceptives were significantly younger than those using permanent methods (mean difference=10.83, p
