Family Planning Clinic Visits Present Opportunities For Providers to Screen for Mental Health Problems

Depression is not uncommon among women attending family planning clinics, and its association with sexual and reproductive health characteristics suggests that obstetricians and gynecologists are well situated to identify women with mood disorders and contribute to their care.¹ One in five women surveyed at clinics in southeastern Texas had moderate or severe depressive symptoms, and these women had significantly elevated odds of having used hormonal contraceptives before age 13 or having had multiple partners. They also were more likely than women without such symptoms to have had a sexually transmitted disease (STD), not to have used a contraceptive at last intercourse, not to have had sex in the last three months or to have had intercourse under the influence of alcohol or drugs.

All women who were neither pregnant nor postpartum and who made a first clinic visit between October 1999 and November 2000 were eligible to participate in the survey; the analyses are based on responses from 4,726 women who were sexually experienced and aged 40 or younger. Twenty-five percent of the sample were Hispanic, 22% black, 48% white and the rest members of other racial or ethnic groups. One-third of the women had not finished high school, half did not work outside the home and half lived in rental housing. One-third were married, and half were unmarried but had a partner.

As measured on a standard scale, 31% of women had symptoms of depression—12% mild, 14% moderate and 5% severe depression. In bivariate analyses, having moderate or severe depressive symptoms was associated with a wide range of variables related to women"s background, contraceptive and sexual behavior, substance and tobacco use, and awareness of family members' contraceptive and sexual behavior and substance use. The researchers conducted logistic regression analysis to determine which of these variables were independently associated with moderate or severe depression.

In the multivariate analysis, 11 variables were significantly associated with depression; five of these pertained to women"s contraceptive and sexual behavior. Nearly three-quarters of the sample reported having had more than one sexual partner, and the likelihood of depression was elevated for these women (odds ratios, 1.4 for those with two or three partners, 1.7 for those with four or five, and 2.1 for those with more). Most of the women had used hormonal contraception; the 2% who had done so before age 13 had twice as high odds of being depressed as women who had first used a hormonal method at age 18 or older (2.0). The odds were elevated among the 26% of women who had not used a contraceptive at last sex (1.4) and among the 19% who said they had ever had an STD (1.3). One in 10 women had not had sex in the previous three months, and one in four had done so under the influence of drugs or alcohol; women in both of these groups were more likely to be depressed than were women who had had sex but not under the influence of any substance (1.5 and 1.3, respectively).

Two of the variables that were associated with moderate or severe depression reflected women's awareness of family members' sexual health-related behaviors or concerns. The 24% of women who had heard a family member express concern about acquiring an STD and the 15% who had heard discussion about substance use before sex had a greater likelihood of being depressed than did those who had not had these experiences (odds ratios, 1.5 and 1.3, respectively).

Depression also was associated with three background variables and one measure of tobacco use. Hispanic women were more likely than whites to be depressed (odds ratio, 1.4), women who had not completed high school had higher odds of depression than college graduates (1.4-1.7), and unemployed women had a greater likelihood of depression than those who worked at least 20 hours a week (1.4). Regular smokers were more likely than women who had never smoked to be depressed (1.7).

Given the prevalence of depression in this population, the researchers point out that "women's health care providers have the opportunity to provide a valuable service by screening for this disorder." Providers could incorporate questions on depressive symptoms into the medical history to identify women with depression, and could then monitor these women, refer them for further evaluation or treatment, or inform them about available resources. Additionally, knowing that a woman suffers from depression could alert a provider that she may have difficulty using particular contraceptive methods.

—D. Hollander

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