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The Effect of Hormonal Contraception on Antidepressant Use Evidence

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The Effect of Hormonal Contraception on Antidepressant Use Evidence The effect of hormonal contraception on antidepressant use Evidence from a free hormonal birth control program Liselotte Seljom Master of Economic Theory and Econometrics UNIVERSITETET I OSLO May 2018 II The effect of hormonal contraception on antidepressant use: Evidence from a free hormonal birth control program Master’s Thesis written by Liselotte Seljom to obtain the degree of Master of Economic Theory and Econometrics Supervised by Professor Edwin Leuven at the Department of Economics at the University of Oslo © Liselotte Seljom 2018 The effect of hormonal contraception on antidepressant use: Evidence from a free hormonal birth control program Liselotte Seljom http://www.duo.uio.no/ Trykk: Reprosentralen, Universitetet i Oslo III IV Abstract The prevalence of depression among young people in Norway varies greatly between the genders. Adolescent girls report a three times higher experience of depressive symptoms as their peer boys. At the same time hormonal birth control is found to be associated with higher rates of depression. While suggesting it is unclear whether this relationship is causal. This thesis aims to analyze the effect of a subsidy on hormonal contraception consumption and the subsequent use of antidepressants. To do so, we will exploit a policy experiment that took place May 2008 until May 2009 where women in the age group 20-24-years old and living in a geographic limited part of Norway were offered free hormonal contraceptives. The analysis will use prescription data collected from the National Prescription Register “Reseptregisteret” and investigate the impact of hormonal contraceptive use on antidepressants, using a difference-in-differences framework. V Preface First and foremost, I would like to thank my supervisor Edwin Leuven for his excellent guidance through engaging knowledge and insightful comments. I am also very grateful to Menon for supporting this thesis by covering the cost of the data set applied and a special thanks to Marcus Gjems Theie in that regard. I am also grateful for the help I have received from the National Prescription Register in the process of creating and applying for the data set. I would like to thank Jørgen Larsen, Vidar Rugset and Kim Dennis Seljom for comments on earlier versions and I would also like to thank my friends, family and colleagues for their various contributions and encouragement. All errors are my own. VI Table of contents 1 Introduction ........................................................................................................................ 1 2 Literature ............................................................................................................................ 3 3 Data .................................................................................................................................... 5 4 Empirical approach .......................................................................................................... 12 5 Results .............................................................................................................................. 18 6 Conclusion ........................................................................................................................ 32 References ................................................................................................................................ 33 A Appendix .......................................................................................................................... 34 B Analysis code ................................................................................................................... 38 VII VIII 1 Introduction Hormonal contraception is a popular method of fertility control used by women in Norway. Statistics collected from the National Prescription Register’s website show that 57% of Norwegian women in the age group 20-24-years old redeemed at least one prescription of hormonal contraceptives in Norway in 20171 (Reseptregisteret, 2018). Combined oral contraception2, also commonly known as “the pill” are the most chosen method of hormonal contraception. About 100 million women worldwide used the combination pill as their birth control in 2003 (Diana B. Petitti, 2003). For most hormonal contraceptives the occurrence of mood swings and depressive symptoms can be found among the potential side effects listed in the package insert (Felleskatalogen, 2018). In Norway, and other countries, the occurrence of reported depression is equal between girls and boys before puberty (Bakken, 2017). As of puberty and out a gender disparity occurs and during the adolescent years, girls experiences depressive symptoms twice as frequent as their peer boys (Reneflot, Aarø, Aase, Reichborn-Kjennerud, & Tambs, 2018). The gender difference in depression seems to puzzle researchers as a clear reason for the presence of it is yet to be found. (Nolen-Hoeksema & Girgus, 1994) (Weissman & Klerman, 1977). Angold et al. (1999) suggest that the causal explanation of the increase in depression among women needs to focus on changes in hormone levels. Recent studies have linked the synthetic hormones found hormonal contraception to subsequent adolescent depression (Skovlund et al. (2016), Zettermark et al. (2018). From May 2008 until May 2009, the women aged 20-24-years living in either Tromsø or Hamar were subsidized with free hormonal birth control. This “free program” was a part of a study on young women’s contraception habits and the correlated effect on abortion rates (Øren, Leistad, & Haugan, 2010). This thesis uses prescription data collected from The National Prescription Register to analyze the effect of subsidy on hormonal contraceptives consumption and on the subsequent use of antidepressants. The collected data set covers the prescription taken out in Tromsø, Hamar, 1 94 344 women in age group 20-24 took in 2017 out at least one type of hormonal contraceptive from ATC- group G03A (Reseptregisteret, 2018). 2 Combined oral contraceptives contains two kinds of hormones: estrogen and progestin. There is also progestin- only pill, called mini-pill, that only contains progestin without estrogen. (Felleskatalogen, 2018) 1 Bodø or Porsgrunn since 2004 and is analyzed with a difference-in-difference framework. Bodø and Porsgrunn are used as control municipalities. Tromsø is compared to Bodø and Hamar is compared to Porsgrunn. The women living in the participating municipalities were also surveyed twice, in the beginning of the free program in 2008 and after it had ended in 2009. 93% in 2008 and 92% in 2009 reported that they had used hormonal contraception in their life time (Øren, Leistad, & Haugan, 2010). One of the main reasons for not utilizing hormonal contraception or discontinuing was “fear of side effects” (Øren, Leistad, & Haugan, 2010), and where women reported that the type of information regarding hormonal contraception they wanted more of, 67% in 2008 and 68% in 2009 answered “side effects”, where hormonal contraceptives association with mood swings and depression were frequently mentioned. The results in this thesis show that the subsidy in 2008/2009 increased the consumption of hormonal contraception. There are larger increases of some methods of hormonal contraception than other, and this also varies across the treated municipalities. There does not seem to be association of the increased hormonal contraception during the free program with the use of antidepressants during the free program. 2 2 Literature Although there has been research on the association of hormonal contraceptives and depression for almost as long as hormonal contraception has been available3, the question of whether there is a causality between hormonal contraception and depression, is still inadequately addressed. Böttcher et al. (2012) concluded that the effects of hormonal contraceptives on the onset or severity of depressive disorders were still unclear. Böttcher et al. found two main confounders, in the existing analysis and available data, that made it hard to draw a conclusion on the overall effect of hormonal contraceptives on depression. This was due to inconsistent use of the term “depression” and a large number of different compositions/methods of hormonal contraception. Skovlund et al. (2016) is a Danish cohort study that combined data from the National Prescription Register and the Patient Register from the Danish population of adolescent girls and young women. Skovlund et al. find that hormonal contraception is associated with subsequent use of antidepressants, especially among adolescents. They compared the probability of women on hormonal contraceptives to start on antidepressants or get a depression diagnosis compared to women who did not use hormonal contraceptives. Zettermark et al. (2018) is a pharmacoepidemiological study on 800 000 Swedish women. In Sweden depression rates for girls/women are twice as high compared to boys/men after puberty, with negligible disparities between the genders before puberty. In their research they apply a combined data set of prescription register and patient register data and they find that there is strong association from hormonal contraception on subsequent depression among adolescents, though not among adults. In 2007 SINTEF was asked by the Norwegian Directorate of Health to research women in the age group 20-24-years’ habits regarding contraception and abortion. To test this, SINTEF did a case study with two treatment municipalities Tromsø and Hamar where women in the age group 20-24
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