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Medscape Now! Hot Topics in Mental Health July 2023

  • Authors: News Authors: Batya Swift Yasgur MA, LSW and Pauline Anderson; CME Author: Hennah Patel, MPharm, RPh
  • CME / ABIM MOC / CE Released: 7/12/2023
  • Valid for credit through: 7/12/2024, 11:59 PM EST
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  • Credits Available

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    ABIM Diplomates - maximum of 0.25 ABIM MOC points

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Target Audience and Goal Statement

This activity is intended for psychiatrists, neurologists, nurse practitioners, primary care physicians, physician assistants, nurses, pharmacists, and other healthcare professionals involved in patient care.

The goal of this activity is for learners to be better able to evaluate emerging studies on mental health issues and the prevention and management of psychiatric disorders.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding
    • Recent advances in the prevention and management of mental health disorders
    • Implications for the healthcare team to improve patient care


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News Authors

  • Batya Swift Yasgur MA, LSW

    Freelance writer, Medscape


    Batya Swift Yasgur MA, LSW, has no relevant financial relationships.

  • Pauline Anderson

    Freelance writer, Medscape


    Pauline Anderson has no relevant financial relationships.

CME Author

  • Hennah Patel, MPharm, RPh

    Freelance Medical Writer


    Hennah Patel, MPharm, RPh, has no relevant financial relationships

Editor/Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC​


    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Esther Nyarko, PharmD, CHCP

    Director, Accreditation and Compliance, Medscape, LLC​


    Esther Nyarko, PharmD, CHCP, has no relevant financial relationships.​​​

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Medscape Now! Hot Topics in Mental Health July 2023

Authors: News Authors: Batya Swift Yasgur MA, LSW and Pauline Anderson; CME Author: Hennah Patel, MPharm, RPhFaculty and Disclosures

CME / ABIM MOC / CE Released: 7/12/2023

Valid for credit through: 7/12/2024, 11:59 PM EST


Advances in mental health care are continuously emerging, challenging all members of the interprofessional team to remain aware of updates in the field and their impact on clinical practice. This article highlights recent developments in our understanding of how oral contraceptives affect depression risk, and gender-specific biological responses to acute stress.


Oral contraceptive (OC) pills have been used over the past few decades. According to most recent estimates in 2019, 150 million women across the globe were using OCs primarily to prevent pregnancy.[1] Other indications for OCs include menstrual-related pain, irregular menstruation cycles, endometriosis, and fibrosis. Nevertheless, there are also adverse events associated with using OCs.[2] Recent large-scale, real-world studies have found an association between OC use and increased risk for depression and use of antidepressants.[3]

In a new population-based study, researchers tracked more than 250,000 women from birth to menopause, gathering information about their use of combined contraceptive pills (progesterone and estrogen), the timing of the initial depression diagnosis, and the onset of depressive symptoms that were not formally diagnosed. They found that OC use was linked to increased depression risk, especially within the first 2 years following initiation.[3]

In addition, OC use in adolescence was tied to an increased risk for depression later in life.

Women who began using these OCs before or at the age of 20 experienced a 130% higher incidence of depressive symptoms, whereas adult users saw a 92% increase. But the higher occurrence of depression tended to decline after the first 2 years of use, except in teenagers, who maintained an increased incidence of depression even after discontinuation.

This effect remained, even after analysis of potential familial confounding.

The study was published online June 12 in Epidemiology and Psychiatric Sciences.

Inconsistent Findings

Previous studies suggest an association between adolescent use of hormonal contraceptives (HCs) and increased depression risk, but it's "less clear" whether these effects are similar in adults, the authors write. Randomized clinical trials have "shown little or no effect" of HCs on mood. However, most of these studies didn't consider previous use of HC.

The researchers wanted to estimate the incidence rate of depression associated with first initiation of OC use as well as the lifetime risk associated with use.

They studied 264,557 female participants in the UK Biobank (aged 37 to 71 years), collecting data from questionnaires, interviews, physical health measures, biological samples, imaging, and linked health records.

They estimated the associated risk for depression within 2 years after starting OCs in all women, as well as in groups stratified by age at initiation: before age 20 (adolescents) and age 20 and older (adults). In addition, the investigators estimated the lifetime risk for depression.

Time-dependent analysis compared the effect of OC use at initiation to the effect during the remaining years of use in recent and previous users.

Adolescents at Highest Risk

Of the participants, 80.6% had used OCs at some point.

The first 2 years of use were associated with a higher rate of depression among users, compared to never-users (HR 1.79; 95% CI: 1.63, 1.96). Although the risk became less pronounced after that, ever-use was still associated with increased lifetime risk for depression (HR 1.05; 95% CI: 1.01, 1.09).

Adolescents and adult OC users both experienced higher rates of depression during the first 2 years, with a more marked effect in adolescents than in adults (HR 1.95; 95% CI: 1.64, 2.32; and HR 1.74; 95% CI: 1.54, 1.95, respectively).

Previous users of OCs had a higher lifetime risk for depression, compared to never-users (HR 1.05; 95% CI: 1.01, 1.09).

Of the subcohort of women who completed the MHQ (n = 82,232), about half reported experiencing at least one of the core depressive symptoms.

OC initiation was associated with an increased risk for depressive symptoms during the first 2 years in ever- vs never-users (HR 2.00; 95% CI: 1.91, 2.10).

Those who began using OCs during adolescence had a dramatically higher rate of depressive symptoms compared to never-users (HR 2.30; 95% CI: 2.11, 2.51], as did adult initiators (HR 1.92; 95% CI: 2.11, 2.51).

In the analysis of 7354 first-degree sister pairs, 81% had initiated OCs. A sibling's OC use was positively associated with a depression diagnosis, and the co-sibling's OC use was also associated with the sibling's depression diagnosis.

The main limitation is the potential for recall bias in the self-reported data, and that the UK Biobank sample consists of a healthier population than overall UK population, which "hampers the generalizability" of the findings, the authors state.

Additional Research Needed

Commenting for Medscape Medical News, Natalie Rasgon, MD, founder and director of the Stanford Center for Neuroscience in Women's Health, Stanford, California, said the study was "well-researched" and "well-written" but had "methodological issues."

She questioned the sibling component and commented that the effect may be "important but not causative."

The authors also didn't study the indication for OC use. Several medical conditions are treated with OCs, including premenstrual dysphoric disorder. Including this "could have made a huge difference in outcome data," said Rasgon, who was not involved with the study.

Also commenting for Medscape Medical News, Anne-Marie Amies Oelschlager, MD, professor of obstetrics and gynecology, University of Washington School of Medicine, Seattle, noted participants were asked to recall depressive symptoms and OC use as far back as 20 to 30 years ago, which lends itself to inaccurate recall.

"This study is too flawed to use meaningfully in clinical practice," Oelschlager concluded.

Implications for the Interprofessional Healthcare Team

  • The interprofessional healthcare team should advise all women on the short- and long-term benefits and risks associated with OC pills
  • The team should consider the role of OCs when assessing depression in women who use this form of contraception


The ability to regulate and adapt emotions is an essential part of daily functioning. During periods of acute stress, emotional regulation supports individuals to recover from challenging situations.[6] Indeed, acute stress impacts decision-making, and differences in emotional response to stressful situations may vary among males and females.[7]


A new study provides early evidence of sex differences in rapid effects of stress systems on the cognitive control of negative emotions.[6]


  • The study included 80 healthy participants, mean age 24 years
  • Half the subjects immersed their nondominant hand (including the wrist) in ice water for up to 3 minutes; the other half, which served as the control group, immersed their hand in warm water for 3 minutes
  • Participants were asked to deliberately downregulate emotional responses to high-intensity negative pictures
  • Participants regularly provided saliva samples to check cortisol levels and were monitored for cardiovascular activity
  • Researchers assessed pupil dilation, which along with subject ratings of their affective state served as emotion regulation (ER) outcome measures


  • In men, stress rapidly improved the ability to downregulate emotional arousal via distraction that was fully mediated by cortisol
  • In women, sympathetic nervous system (SNS) reactivity was linked to decreased regulatory performances
  • Direct stress effects on ER were smaller than expected


The study contributes to a "better understanding of the neuroendocrinological mechanisms of stress effects on ER that may help to develop adequate preventive and curative interventions of stress- and emotion-related disorders," the researchers write.


The study was conducted by Katja Langer, Valerie Jentsch, and Oliver Wolf from the Department of Cognitive Psychology, Ruhr University Bochum in Germany. It was published in the May 2023 issue of Psychoneuroendocrinology.


The results have some inconsistencies. The ER paradigm is somewhat artificial and not fully comparable with emotional trigger and regulatory requirements in everyday life. The study did not directly assess levels of catecholamines such as adrenaline and noradrenaline.

Implications for the Interprofessional Healthcare Team

  • It is important for the interprofessional healthcare team to recognize that men and women may have different biological responses to acute stress
  • The team should be mindful of this when managing stress-related health conditions

This transcript has been edited for style and clarity.


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