depression

Depression and Anxiety in Geriatric Patients

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On this week’s episode of the podcast, I am joined by Dr. Carolina Osorio, a geriatric psychiatrist (and one of my favorite people). After she finished her psychiatry residency, she also went on to finish a fellowship in geriatric psychiatry to take care of her favorite people. Dr. Osorio runs a special program that treats elderly people with depression and anxiety.


Mental health in the elderly

Sylvia Yu (MS3), David Puder, M.D.

As many people age, their health declines, and their needs increase. At the same time, we can experience loss of spouses because of aging, loss of friends and fear of death. We can lose eyesight, hearing, and subsequently, our drivers licenses and autonomy. It can be an incredibly stressful and lonely time.

At this time in history, like no other time before, we are experiencing a wave of baby boomers that will put a new strain on our already waning mental health facilities. Baby boomers are also more likely to stigmatize using mental health services.

Dr. Osario noticed these problems and she took steps to create a program that is helping her local aging population in a way that makes them feel comfortable.

If you are a primary care physician, psychiatrist, or a family member that is a caretaker for the elderly, this article will have takeaways from Dr. Osorio’s program that can help clarify how we can best help the aging population.  

When Dr. Osorio was a resident, she noticed that in mixed-age groups, older adults didn’t get the treatment that they needed. A general outpatient partial program wasn’t benefiting them, and sometimes it would make them worse because older adults tend to become parents to their younger peers in their group. She noticed that the older adults ended up taking care of their younger counterparts and not getting the individualized help they needed.

She started building a program to help the elderly in the way that they needed to be helped—through diet, exercise, therapy, medication management and stress reduction.

Medically, older adults have comorbidities, or more than one medical issue that needs to be treated. Because of this, having a geriatric therapist, group therapy session, or a geriatric mental health program can keep them happier, healthier and independent for longer.

If you run an outpatient group for the elderly, if you’re suggesting one for your patient, or if you are looking for one for an elderly friend or relative, here are a few things to consider:

  • Small groups - It takes longer to express their stories, to receive feedback, and to cognitively process information. Because of this, there should be no more than 8 participants in any one session.

  • Medication support/management/consultation - Often, elderly people are on too many medications, and this could be slowing them down physically, causing mental decline, and speeding up the aging process. We will make suggestions below on how medications can be managed.

  • Evidence-based therapies - A good outpatient elderly care program will also include evidence-based therapies (Bartels, 2003) to help the patients cope with their depression and anxiety, such as cognitive behavioral therapy (CBT), problem solving (Malhouff, 2007), reminiscence therapy (Elias, 2015), nutrition education, and medication education. Below, we will go into these therapies and why they are helpful.

Medications for aging adults

Benzodiazepines

Unfortunately, many elderly patients are prescribed benzodiazepines—drugs used to treat anxiety. Many primary care doctors have busy schedules with short appointment times. When the patient has hypertension, diabetes and osteoporosis, mental health can take a back seat to managing the more urgent health issues. The primary care doctor will usually just prescribe a benzodiazepine to deal with the anxiety issues.

There are several problems with giving benzodiazepines to the elderly. With time, the body gets used to the benzodiazepine, and the doctor starts to increase the dose. Then, the patient typically becomes even more depressed, more lethargic. This, in turn, increases other health issues.

That is why special consideration should be given when prescribing “benzos” to the elderly. It is also why Dr. Osorio’s goal in her outpatient program is to taper them off of their benzodiazepine medications. She says many of the patients she sees have been on them for 20-30 years.

Tapering a patient off of a benzo should be done very, very slowly in order to avoid delirium or worsening of anxiety.  

For example, if the patient is on 4mg of Xanax a day, Dr. Osario will convert them to Klonopin. Because of the half-life of the medication, the patient will have fewer symptoms of withdrawal when they start coming off of it. Then, she would reduce the dosage to 3mg of Klonopin over the next six months to a year.

Anticholinergic medications

As we age, our brain changes and there are parts of the brain that are going to have synapses that decrease. Acetylcholine actually decreases with age. But, if you add a medication that is anticholinergic, you are putting a bigger burden into that normal process. Then, there can be bad side effects such as confusion and dementia.

Because of that, Dr. Osorio says she will typically taper off or replace any medication with an anticholinergic burden. For example, the antidepressant Paroxetine is a no-go drug in the elderly population because it is very anticholinergic. The tricyclic antidepressants are also very anticholinergic. Nortriptyline, however, is one that Dr. Osorio would prescribe because it has much less of the anticholinergic burden at lower doses.

(I will put a list up on my website in my resource library of the different medications that are anticholinergic. Along with “Beers list,” medications that are contraindicated in older adults.)

Lithium

Physicians don't often think about lithium. Lithium is brain-protective (Forlenza, 2014). It has many functions that are very healthy and it actually produces neurogenesis in some patients. Consider, if you have a patient on an SSRI that isn’t responding how you’d like, adding a tiny dose of lithium (usually about 150-300mg).


Medication management for the elderly

Psychiatrists must work very closely with the patient’s primary care doctors. There are primary care doctors who also have a fellowship in geriatrics, but most do not have the specialized training needed to maximize mental health and minimize side effects. Sometimes it is helpful to have a conversation on behalf of the patient and guide them in certain medications. Every doctor should think about the whole body in general, and working with a primary care doctor can help psychiatrists do that.

A lot of older adults start feeling better when you start decreasing their meds. This indicates they were just depressed and did not have Major Depressive Disorder that required a heavy load of medications to manage it. It also shows that the depression was a side effect of medications. That, really, is the first thing you want to think about when you have a new patient and you see a very large list of medications that they are taking—are the symptoms because of the medication or is the medication helping alleviate symptoms? Should they be taking every single medication on the list?

There are a couple of studies that have talked about serotonin in older, depressed patients and how that can delay the progression of mild cognitive impairment of Alzheimer’s (Smith, 2017). One study showed that SSRIs are the best medications for it—Wellbutrin, SNRIs, tricyclics. There is actually another study done with older adults who had mild cognitive impairment and a history of depression (Bartels, 2018). Those who were taking SSRIs delayed progression of mild cognitive impairment by three years. But, in those patients who were put on another type of antidepressant, the progression was faster.

However, it is important to note that putting an elderly patient on an SSRI does not deal with the root of the issue. Therapy in conjunction with medication has been shown to be more powerful and sometimes eliminate the need for medication. If the patient is lonely, eating poorly, and has no life activities to look forward to, changing those factors can decrease the need for medication. Always consider therapy in addition to any psychiatric medication.

No matter what you prescribe, the patients have to take the medication for it to be helpful. Make sure to write down the medication, dosage, and times in clear language. Help the elderly patient understand what to take and when. When necessary, get helpful family members involved to remind the patient as well.

Therapy for the elderly

Another component of aging healthfully is receiving therapy. The cognitive load of aging alone, including the sum total of traumatic experiences, is often enough to require therapy to help with life transitions.

There are many forms of therapy available that can help the elderly experience a fuller life, deal with trauma safely, manage their depression and anxiety, and even stay mentally sharper for longer.


Problem solving therapy for the elderly

Problem-solving therapy is a way of teaching the elderly how to find ways to solve the particular problems that are unique to them. These problems cause anxiety and depression, so teaching them how to think about them, how to solve problems themselves, can give them a sense of autonomy and control. Sometimes, in therapy, you cannot solve the actual problem, per se, but the process of working through it together gives them different options that they can utilize if their anxiety starts to spike when they are alone.

For example, one elderly lady Dr. Osorio works with struggles with terrible anxiety. She recently broke her arm. She couldn’t clean her home, and her family would come over to help. She felt like a burden to them and was very anxious about this. During problem solving therapy, they  made a list of all of the things that needed to be done around the house, and then they marked the three things she could do, even with her broken arm, to help. She felt better knowing she could help her family while they were helping her. Even though we couldn’t fix the problem, we made it manageable, and gave her some autonomy back.


Reminiscence therapy for the elderly

In reminiscence therapy, you focus on reminiscing about good things. For example, Dr. Osorio will bring her elderly patients a picture of a turkey. She will ask them what it reminds them of. Everyone starts talking about Thanksgiving with their families. They discuss memories, smells, and they walk through the senses of what it was like for them at a happy time. This alone starts to fire up positive emotions in their brains and can change their moods instantly.

The cool thing about reminiscence therapy is that it even works with patients who have dementia, because their long-term memory is pretty solid. They can dip into their past and they immediately start brightening up. Their whole countenance changes.

It is a simple therapy to use, and it can be very helpful when dealing with depressed patients. They often feel alone, but when they begin to talk about the good times and share memories, it connects them to others in their group, and helps them make positive social connections.

Cognitive behavioral therapy for the elderly

There are also behavioral activations we can implement to help the elderly. The elderly patient typically has a hard time with scheduling routines. As their therapist, it can be helpful to get them to schedule a solid routine they can stick with because we have to break the cycle of depression and anxiety. For example, if you're depressed, you want to be in bed, you stay in bed, you get more depressed. This is damaging to an elderly person because it is much harder to get them to start scheduling and moving around again once they slow down. Activating their schedule can be a first step in keeping them independent for longer.

For elderly cognitive behavioral therapy, first, we do education on this process and then start helping them find ways in which they can break that lethargic routine. We want to help them choose an activity that they want to do so that it’s easier to break that cycle. Maybe that is going every Sunday to visit their grandkids. Maybe they can join a card game club, join a church, a quilting group, a storytelling group or take a community educational class. That one simple thing can break their cycle of depression, ease loneliness, and keep them engaged for longer.  

Aging and brain health

The evidence for maintaining brain health while aging says there are several things we can do to stay healthy: physical activity, socialization, nutrition and stress management.

Physical exercise

Dr. Osorio’s favorite exercise to recommend for the elderly is tai chi. Tai chi decreases the risks of falls in older adults (Lomas-Vega, 2017). There are even insurances that are starting to pay for tai chi for older adults because it is cheaper than fixing a broken hip. It’s a very easy, very smooth exercise.

For the wheelchair-bound, she recommends chair exercises. A physical therapist can help the patient move their arms, their torso, their necks. Maybe some of them can lift their legs from the knee up. Even if they can’t, they can still get a good exercise in and get some positive movement going.

When the elderly patient is doing really well in exercise they can start to add weights. Weights are very important because when they use weights their muscles are contracting and they’re positively impacting those bones. This is a good way to decrease osteoporosis. Even with the elderly, muscles can get stronger and their strength can increase. Studies even show that exercise in the elderly pretty much halts the dementia progression.


Socialization

Socialization is also very important. One study showed that the higher risk factor for morbidity and mortality was related to isolation (Holt-Lunstad, 2015). Isolation is actually toxic for our brains. If someone is home alone, they will usually die faster.

Being with friends and family and maintaining a social life helps the brain because it uses visuospatial skills, social skills and cognition. A simple conversation, a regular visit with a loved one or a new person can help an elderly person maintain positive brain health.

Human connection is necessary throughout all of life, and to have close, connected friends makes a huge difference. As part of her program, Dr. Osorio notices if they're having issues making friends, and she helps them create some behavioral activation to get them to places where there is a potential of making friends.


Nutrition

As far as nutrition goes, we have to take into account that the elderly population is pretty diverse. There are 60 year olds who are very fragile because of many health problems and there are 90 year olds who are pretty healthy.

Dr. Osorio personally recommends the Mediterranean diet. The Mediterranean diet is a diet that consists of grains, fish, olive oil, avocado, fruits and vegetables. The Mediterranean diet offers omega-3 fatty acids in the fish, high poly and monounsaturated fats in the olive oil and in the nuts.  There is also a lower amount of sugar then the average American diet. If elderly patients are struggling with making the big change in their diets, it’s best to merely suggest they don’t consume processed foods.

The Mediterranean diet has been associated with a reduced risk of developing mild cognitive impairment (MCI) or progressing to Alzheimer disease from MCI (Scarmeas, 2009). This year it was the number one diet recommended by the medical field.


Stress management

Stress reduction also adds to positive brain health. Mindfulness and visualization are both helpful practices to reduce stress. Stress reduction is not a one-time fix all. It is something that has to be practiced every single day in order to work.

Ask the patient to download a meditation app if they are technologically savvy, or even join a meditation group for seniors to increase their socialization. If neither of those works, getting them to quietly rest and close their eyes for even five minutes with the intention of relaxing, not just to nap or sleep, can have positive benefits.

Conclusion

If you work with the elderly, or know someone who is elderly, if they struggle with mental health issues such as anxiety and depression, or have comorbidity with other health issues, consider suggesting an outpatient group therapy for the elderly. It can be extremely helpful when paired with nutrition, exercise, and a cohesive plan with their primary care physician.

Other episodes I HIGHLY recommend if you are interested in treating elderly people:

Sensorium: Total Brain Function Optimization Part 1

Psychiatric Approach to Delirium with Dr. Timothy Lee

Questions, comments, thoughts? Please comment on the picture that corresponds to this post on my instagram: @Dr.DavidPuder

Hormonal Contraceptives & Mental Health

Do Hormonal Contraceptives Cause Depression? How Do Estrogen and Progesterone Influence Behavior and The Brain?

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Many women take hormonal contraceptives as a way of preventing pregnancy, or for other health reasons. These contraceptives basically use hormones to stop your body from ovulating.

But do you ever wonder if changing your hormones can affect more than just your chances of getting pregnant?  

Birth control has many positive effects too, other than just preventing unwanted pregnancy. It can help with:

  • Acne

  • Depression in elderly

  • Hirsutism

  • Heavy periods

  • Maintaining bone density

  • Decreased risk of certain cancers

  • Premenstrual dysphoric disorder

How hormones work without the pill

In a woman that’s not on the pill, early in their cycle, they’ll have the least amounts of estrogen and progesterone in their body. Around ovulation, estrogen will rise, which changes their mood, causing them to experience more of the reward hormone, dopamine, and even the happy hormone, serotonin. Later in the cycle, progesterone rises too, changing the emotional state again. The drop in hormones and Progesterone is the depressant hormone, so this is typically what causes the pre-period moodiness that some women feel.

This hormonal shift does not happen, or happens very subtly in women who are on birth control.

Using a hormonal contraceptive changes your body’s chemistry, and alters your hormones. When you change your body chemistry, you may have influences on your mood, desire, all sorts of things we wouldn’t normally consider when we are only looking for the benefits.

Here are some of the things hormone contraceptives can effect:

What women find attractive

Scientists noticed that women who were ovulating, and not on the pill, had an increased attraction to more masculine faces, dominant male behavior, taller men, deeper voices, versus when they were not ovulating. Ovulating women also wanted to go to public events more, and had more sexual fantasies. When they weren’t ovulating, women looked for a man who is more empathic, more fatherly, more compassionate.

Depression

One study followed a group of women for a number of years to see if their mood changed. They found that the younger (15-19) contraceptive group was 1.7-1.8 times more at risk of depression and being prescribed antidepressants. Specifically, younger women (15-19), and those who were prescribed progesterone-based pills, were at highest risk of depression. Also, most of these women experienced the depression onset at around 2 months - 1 year.

If you’re older, taking a more estrogen-based hormone, have been on it for awhile, and are not depressed and have been taking hormonal contraceptives for more than one year, I would say you are probably not at risk of developing depression because of contraceptives. Now, that said, there are tons of reasons that people get depressed—life situations, genetics, health—it’s not just related to hormones. If you are concerned about depression, talk to your doctor about it.

Natural fear response

Women who are on hormone contraceptives are more likely to experience anxiety. Natural hormone levels help with fear extinction, or the ability to overcome fears. Birth control can inhibit our ability to regulate fear in stressful situations.

Empathy

In the part of the natural cycle, before ovulation, when estrogen is higher, women have an increased ability to recognize facial expressions of emotion. Hormonal contraceptives decrease brain responsiveness, making it more difficult to process emotion, and making recognition of negative emotions harder.

Reward Pathway

Ovulation also causes an increase in estrogen, which increases the brain reward pathways by increasing dopamine, our body’s pleasure response hormone.

If you are on an oral contraceptive, the changes in hormones can cause a dampened reward processing, so there may be a decreased amount of pleasure you can experience through things like food, sex, or even social connectedness.

My conclusion about the pill

Overall, with the positive effects birth control has caused in society, namely, a decrease in teen pregnancy, it can be difficult how to integrate the new details emerging on the influence on mental health.

I know my research into this has led me to be more aware of teens I treat who are taking hormonal contraception.  If you’re looking for the benefits of the pill, there are many types of contraceptives, and because every woman is different, there is not a one-size-fits-all option. Talk to your doctor about which one is best for you.

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Below are more detailed notes that Dr. Mona Mojtahedzadeh and Dr. David Puder worked on together to provide the scientific foundation to this episode.

Intro:

  • Our goal is to empower women to know more about the recent debate in the relationship between contraception and mental health.

  • I first started thinking about this after hearing a talk by Kelly Brogan

  • Worldwide, 100 million women use “the pill”.

  • Approximately 82% of sexually active women in the USA use oral contraceptive pills (OCP) sometime during their reproductive years.

  • 17% of women aged 15-44 use “the pill”.

  • The last decade in the USA, rates of teenage birth rate along with teenage pregnancy and abortion have decreased. Most researchers attribute this victory to improved access to contraception. (Carrol, 2017- New York Times)

  • OCPs are prescribed for various reasons: prevention of unintended pregnancy; decreased risk of ovarian, endometrial, and colorectal cancers; preservation of bone mineral density; and at times prescribed for PMDD symptoms; acne and hirsutism; heavy menstrual bleeding. (Cheslak-Postava, 2014)

Do Hormonal Contraceptives Increase Risk of Depression?

  • One million women in the Denmark national registry, followed for 6.4 years (Skovlund, 2016), ages 15 to 19 years old had higher risk of depression, even when they had no history of depression.

    • The hormonal contraceptive group age 15-19 had an increased relative risk of 1.7 of first incidence of depression diagnosed in a psychiatric hospital

    • The hormonal contraceptive group age 15-19 had an increases relative risk of 1.8 of first incidence of using an antidepressant

      • Hard numbers are for the non-use, 10k prescriptions of antidepressants over 1.1 million person years vs use of oral combined 18.5k antidepressant prescriptions over 0.91 million person years (RR 1.8).

    • The all progestin-only pill group age 15-19 had a 2.2 risk of first time antidepressant and 1.9 first diagnosis of depression in a psychiatric hospital

    • Risk did not increase till 2 months after initiation of hormonal contraceptive use, peaked at 6 months and after one year decreased significantly

  • Another study of 1236 women, ages 20-39 from the United States National Health and Nutrition Examination Survey (NHANES) found that “women who had used OC during adolescence showed an at least 1.7 times higher 1-year prevalence of depression in adulthood compared to both women who had never used OC, and to women who had only started using OC after adolescence.” (Anderl, 2017)

Some critics:

  • Large-cohort population, based studies (especially if the data is from an administrative database) have more chances to find a statistically significant result even if the results are not clinically significant. However in the Denmark study all correlations showed similar things which would not occur if there was no link, and relative risks were high, especially for adolescent women.

  • Are women who are accessing hormonal contraceptive methods accessing more health care system in general?  

  • Previous studies looking at rates of depression did not find a correlation with OCPs or some even reported improvements in mood. Months earlier there was a systematic review study published in the European Journal of Contraception and Reproductive Health Care. Although they made it clear that we were lacking prospective studies, the data that did exist at the time showed no correlation between hormonal contraception and women’s moods, or actually had improvement in mood. Therefore, this new study has to be weighed along with the rest and can not replace all prior research.

  • In the study it states that for every 100 women who did not used hormonal birth control, 1.7 were later prescribed antidepressant. For every 100 who did use, 2.2 were prescribed antidepressant. The difference is 0.5 percentage points meaning that if this was a randomized control trial, for every 200 women treated, one need to be treated with antidepressant. (Carrol, 2017- New York Times)

  • The amount and types of progesterone hormone varies between different hormonal contraceptives. (Antiandrogenic progesterones are less possible to cause mood lability, lower chances of acne, and lower chances of increased appetite or weight gain.)

  • We should not underestimate the role of molecular genetics in determining effects of hormonal contraceptives on women.

  • “This study showed an association between birth control and depression. Specifically, both women who took oral contraceptives (which go through the bloodstream and to the whole body) and women who had progesterone IUDs (such as the Skyla or Mirena, which concentrate hormones in the uterus) seemed to have higher rates of depression. But like all epidemiologic studies, it can only prove that there is some correlation between hormones and depression (and only in this particular data set), not that one causes the other.” David Grimes, MD

Pathophysiology: How do OCPs work in general compared to natural states of hormonal secretions?

1.  Hormonal levels

  • We want to weigh effects of amounts of hormones vs effects of pulsatility of hormones.  

  • OCPs have much smaller levels of estrogen and progesterone (progesterone> estrogen) compared to a natural woman’s cycle.

  • In general, progesterone is more causative for depressive episodes and estrogen is more to cause elevations in mood. Antiandrogenic progesterones are said to be causing less of mood lability and negative emotional effects.

2.  Mode of secretion

 

  • In the past it has been stated rapid declines in hormones have a negative impact on mood.

  • In natural circumstances, the arcuate nucleus of the hypothalamus functions as pulse generator, resulting in hourly release of gonadotropin releasing hormone (GnRH) in to the hypothalamic-pituitary portal vasculature.

    • This leads to a pulsatile plasma profile of luteinizing hormone (LH) and follicle-stimulating hormone (FSH)

    • LH and FSH lead to a pulsatile increase in estrogen and progesterone.

    • The pulsatile fashion of LH and FSH also regulates the growth and maturation of the graafian follicle in the ovary.

    • Our neural clocks termed the hypothalamic GnRH pulse generator determines the pulse frequency but the amount of GnRH released in each pulse is determined by our estrogen and progestins.

  • OCPs steady state inhibits GnRH therefore there is a lower level of estrogen and progesterone and no longer rapid shifts in estrogen and progesterone.

  • In one study, triphasic OCPs (which correlate more to natural menstrual cycles) were more related to first episode depression than monophasic ones. (Cheslak-Postava, 2014)

 

3.  Feedback mechanisms

  • In a natural menstrual cycle, we have both negative AND positive feedback mechanisms involved. Approaching mid-cycle, we have a 36 hours increase in levels of estrogen which leads to  a surge in FSH, LH further to which we have a second surge in estrogen this time accompanied by progesterone prolonging through the second half of the cycle.

  • OCPs solely act by negative feedback, decreasing hormonal states on all 3 levels therefore resulting in a much decreased states of estrogen and progesterone hormones. The low steady fashion of hormone exposure with OCPs, prevents FSH and LH surges and therefore subsequent ovulation.

  • The pulsatile nature of hormonal secretions is essential for positive feedback mechanisms leading to maintenance of normal ovulatory menstrual cycles.

  • Women are most euphoric around their ovulatory phases.

  • OCPs prevent ovulation by providing a steady level of hormonal exposure therefore preventing the body to go through the plasma surges of the FSH/LH and subsequently the sex steroids. Because of this effect, women on OCP are deprived of the natural mood elevations experienced around and post time of ovulation.

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Point 2: OCP Have Unique Effects on the Brain

  • Hormonal contraceptives cross the blood brain barrier

  • Pulsatile nature of natural hormones

  • In puberty the surges of sex hormones cause organizational changes in the brain (Peper, 2011)

    • “Typical gray matter decreases in prefrontal, parietal, and temporal cortices taking place during puberty and adolescence were found to be related to increased levels of estradiol in girls and to increased levels of testosterone in boys.”

  • OCP bind receptors in different brain regions

    • Immediate changes (seconds to minutes)

      • Decreased endogenous estrogen and progesterone

        • Estrogen inhibits secretion of FSH

        • Progesterone inhibits secretion of LH

        • Absence of normal fluctuations

      • Strongly reduced testosterone levels (to the level of follicular phase)

      • Decreased effect of oxytocin on social-reward processing

    • Epigenetic processes (takes months)

    • 28 women, ages 16 to 35, on hormonal contraception for 3 months were compared to controls and found to have these differences in the brain on MRI. (Lisofsky, 2016) The women on contraceptives had decreased gray matter volume in the left amygdala/anterior parahippocampal gyrus.

    • Sex steroid hormones have effects on the cortical and subcortical regions involved in cognitive and emotional processing. Addition of progesterone to hormone therapy, has been shown to cause adverse mood effects in women. Mechanisms include: activation of (Y aminobutyric acid A) GABA-A receptor which is the major inhibitory system in the central nervous system (CNS) of humans. Also, external progestins more than natural progesterone, increase levels of monoamine oxidase which degrades serotonin concentrations. (Kleiber, 1996)

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  • Hormonal contraceptives decrease the ability to have fear extinction

    • Women have 2x the rate of anxiety disorders, compared to men, specifically starting after puberty

    • Estrogen can reduce fear, by enhancing fear extinction

      • A single dose of estrogen can reduce fear extinction

      • Low estrogen levels are associated with higher fear conditioning

        • In one study, women with lower estrogen when showed a violent video, on subsequent days had elevated skin conductance and when going through a fear extinction task and also had stronger intrusive memories (Wegerer, 2014)

      • High estrogen facilitates fear extinction and protects against the effects of stress by causing:

        • increased activation of the ventromedial prefrontal cortex (vmPFC)- amygdala circuit during fear extinction

        • Increased activation of anterior cingulate cortex (ACC) and dorsolateral PFC during emotional response inhibition important in fear regulation

        • Downregulation of emotional and stress reactivity in the amygdala, hippocampus, hypothalamus, ACC, orbitofrontal cortex

      • Women on OC during fear extinction:

        • Displayed higher activation in the amygdala, thalamus, ACC, and vmPFC, and also had slower habituating skin conductance responses, which could suggest impaired fear extinction

      • Women on OC had decreased reactivity of HPA axis (hypothalamic-pituitary-adrenal axis):

        • When cortisol was given to women on OCs, they had increased hippocampal activation during a fear condition whereas in men or naturally cycling women had decreased activation.

        • When in a non-stressful situation OC users had decreased amygdala activity towards negative pictures (Petersen, 2015)

Empathy

  • A single dose of estrogen in one study increased men’s empathy (increased physiological response to another’s pain, increased emotional (vicarious) reactivity) (Olsson, 2016)

  • A recent systematic review concluded that facial emotional processing is enhanced during the follicular phase and oral contraceptives decreased brain responsiveness during different facial emotion processing tasks.  Postpartum and pregnant women may be in a hypervigilant state in regards to facial emotion processing. (Osorio, 2018)

Reward Pathways

  • Estrogen increases reward pathways by increasing dopamine whereas OC dampen reward processing changing social and sexual stimuli

Partner Selection and Relationship:

  • Women during ovulation had preference to more masculine faces, those on OCs did not have change in preference during the cycle. (Penton-Voak, 1999)

  • Women have preference of more masculine bodies when their fertility is highest (Little, 2007)

    • Other preferences include: vocal masculinity, video clips of dominant behavior, taller men

    • Change in behavior seen: greater interest in public events where they could meet men, more sexual fantasies

  • Women during ovulation are more attracted to more masculine male faces.  This was a study of 42 female volunteers at 2 different phases of their menstrual cycle. In general women favored a more masculine face but during ovulation there was an increased choice for the more masculine face. (Johnston, 2001)

  • In women during the period before ovulation, testosterone normally predicts preference for masculine faces, but in women on OCs there was no link (Bobst, 2014)

  • Preferences change in marriage when women get off of their OCs, if their partner is unattractive they may remain with higher dissatisfaction and if their partner is attractive they will have higher satisfaction (russell, 2014)

  • Another study found that highest sexual satisfaction in women was found in those who either met their partner when not on OC and did not get on an OC or those who met their partner on an OC and continued on an OC (Roberts, 2014)

 

Citations and Further reading:

Further reading on IUD: article showing how uncommonly IUDs are used in the US

Anderl, C., & Chen, F. S. (2017). Oral Contraceptive Use in Adolescence Predicts Vulnerability to Depression in Adulthood.

Bobst, C., Sauter, S., Foppa, A., & Lobmaier, J. S. (2014). Early follicular testosterone level predicts preference for masculinity in male faces–But not for women taking hormonal contraception. Psychoneuroendocrinology, 41, 142-150.

Brunton, L. L., Chabner, B., & Knollmann, B. C. (Eds.). (2011). Goodman & Gilman's the pharmacological basis of therapeutics.

Cheslack-Postava, K., Keyes, K. M., Lowe, S. R., & Koenen, K. C. (2015). Oral contraceptive use and psychiatric disorders in a nationally representative sample of women. Archives of women's mental health, 18(1), 103-111.

Grimes, D. A. (2015). Epidemiologic research with administrative databases: red herrings, false alarms and pseudo-epidemics. Human Reproduction, 30(8), 1749-1752.

Johnston, V. S., Hagel, R., Franklin, M., Fink, B., & Grammer, K. (2001). Male facial attractiveness: Evidence for hormone-mediated adaptive design. Evolution and human behavior, 22(4), 251-267.

Little, A. C., Jones, B. C., & Burriss, R. P. (2007). Preferences for masculinity in male bodies change across the menstrual cycle. Hormones and Behavior, 51(5), 633-639.

Lisofsky, N., Riediger, M., Gallinat, J., Lindenberger, U., & Kühn, S. (2016). Hormonal contraceptive use is associated with neural and affective changes in healthy young women. Neuroimage, 134, 597-606.

Montoya, E. R., & Bos, P. A. (2017). How oral contraceptives impact social-emotional behavior and brain function. Trends in cognitive sciences, 21(2), 125-136.

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Appendix:

  • OCPs have more progesterone than estrogen. They only have small amounts of estrogen to stabilize endometrial lining and to reduce bleeding.

  • OCPs in general cause improved quality of life by different means for example by reducing bleeding.

  • Due to the molecular genetic phenomena, if one OCP not satisfactory, changing to a different one might be a solution.

  • IUDs are not systemically absorbed; therefore, do not inhibit ovulation. They mainly act by inflammatory responses in uterus preventing implantation of the ovum. They also act by increasing cervical mucosal thickness.

  • Copper IUDs act by the same inflammatory responses, also copper elements in the device are said to have paralyzing effects on sperms.

 

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