The stress of infertility and prescription of antidepressants

Published 13 August 2019

A cohort study cross-linking two Danish registries finds positive correlation between infertility-related stress levels and prescribed medication over a ten-year follow-up period.

High levels of physical tress among women having fertility treatment are an important indicator of their need for antidepressant drugs later on, according to a large-scale 10-year Danish register study.(1)

Based on data from more than 1000 women, this is the first long-term cohort study to link the impact of childlessness (as measured by stress levels) with antidepressant prescription. The findings suggest that the risk of needing medication is nearly doubled when a woman's marriage (or relationship) and her personal life are affected significantly by infertility-related stress, especially when failing to give birth following ART.

Co-author Juliana Pedro from the University of Porto, Portugal, said the study provides 'solid evidence' that women should be screened at the outset of their treatment. Mental health professionals must be included in fertility care, she added, to identify at-risk patients and provide psychological support.

'Infertility-related stress is preventable and this action - screening and support - might prevent worse mental health outcomes during and after treatment,' said Pedro, who is currently a Deputy Co-ordinator of ESHRE's SIG Psychology & Counselling.

She added that, while this study focused on women, 'infertility is an issue for couples and marital stress appears to have an important impact on antidepressant's being redeemed [collected] later on. So psychological support should be offered to both partners. This could decrease stress, ease the experience of going through treatment and even prevent the need for antidepressants.'

The research involved 1009 women (mean age 31.8 years) who at the start of the study had been trying to conceive for several (average 3.45) years. None had been prescribed antidepressants before embarking on ART.

The data came from two major registries — the Copenhagen Cohort Multi-centre Psychosocial Infertility (COMPI) cohort, and the Danish National ART-Couple (DANAC) I cohort, which includes all women and partners who received ART from January 1994 to September 2009. Both cohorts are part of the COMPI research programme established in 2000 for investigating psychosocial and medical questions in infertility and its treatment.

Each patient's unique personal identification number was cross-linked to the DANAC I cohort data with other medical information - which included Danish National Prescription registry details of all antidepressant scripts redeemed at community pharmacies. In addition, patient personal identification numbers were used to link the DANAC I and COMPI Infertility cohorts. Information on redeemed prescriptions of antidepressant medication could thus be combined with self-reported data from COMPI. This included levels of infertility-related stress among couples entering treatment at fertility clinics, and how well they were coping.

Stress levels were measured using the COMPI Fertility Problem Stress Scales (COMPI-FPSS), a tool to assess the impact of childlessness on a man/woman's personal and social life. With a high score indicating higher stress levels, COMPI-FPSS also analysed how patients' marriages were affected (for example, with questions about thoughts of break-up/divorce).

ART-treated women were followed until they had redeemed their first prescription for antidepressants, or until 31 December 2009. Researchers excluded anyone prescribed antidepressants prior to filling in the COMPI questionnaire.

Prescribed antidepressants
The findings showed that 14% (n=138) of women had collected their medication from a pharmacy within the 10-year follow-up period. The average time between baseline (the COMPI questionnaire) and first redeemed prescription was 5.7 years, although variation across the sample indicated that some women needed antidepressants sooner than others.

High levels of physical stress (as defined by symptoms including headaches, back pain and nausea) were a predictor for needing antidepressants later on. High personal and marital infertility-related stress levels were significantly associated with antidepressant prescription — almost twice the incidence of those reporting low levels. Among women still childless at follow-up, the association between personal and marital stress and antidepressants was markedly stronger than for those who had become parents. In contrast, social stress (defined as the impact of infertility on a person's relationship with friends and family) was not significantly associated with the need to redeem a prescription.

The authors caution that the study has limitations. Controlling for other negative life events that could explain the need for antidepressants was not possible, and Pedro and her colleagues could not be certain that patients had actually used the antidepressant medication collected from pharmacies. Overall, however, they describe the results as 'important' and worthy of further research.

1. Pedro J, Vassard D, Malling H, et al. Infertility-related stress and the risk of antidepressants prescription in women: a 10-year register study. Hum Reprod 2019

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