Premenstrual Dysphoric Disorder and Psychiatric Comorbidity

Diagnostic Dilemmas—Effective Treatment Approaches

By Deborah R. Kim, MD and Ellen W. Freeman, PhD | April 7, 2010

There are no studies that examine maintenance treatment in women with PMDD and a comorbid psychiatric illness. PMDD is a chronic, recurrent disorder, so it can be assumed that long-term treatment is indicated. Further studies are warranted.

Anxiolytics

Alprazolam, a benzodiazepine, and buspirone(Drug information on buspirone), a 5-HT_1A agonist, have shown modest efficacy in some, but not all, PMS studies. Berger and Presser²⁹ found a poorer response to alprazolam(Drug information on alprazolam) in women with follicular phase anxiety and depression than in those with only luteal phase symptoms. Women took the medication regularly during the luteal phase and on an as needed basis during the follicular phase.

If a woman continues to experience significant premenstrual anxiety, despite treatment with an SSRI, luteal phase treatment with an anxiolytic can be considered.

Hormonal treatments

Estradiol affects 5-HT synthesis and reuptake. Pharmacological suppression of ovulation has been shown to decrease symptoms in women with PMS. Young and colleagues³⁰ reported in the analysis of the STAR*D that 1238 women with depression who took a combined oral hormonal contraception (OCP) report less severe depression. Yet, many women reported increased mood and anxiety symptoms while taking synthetic progestins; this needs to be carefully considered in women with comorbid Axis I disorders. OCPs in general do not improve PMS symptoms, although there may be benefit to the FDA-approved use of the OCP that contains drosperinone 3 mg and ethinyl estradiol(Drug information on estradiol) 20 µg (DRSP/EE) or extended-cycle dosing (fewer hormone-free intervals). In an open-label trial, Joffe and associates³¹ found that an OCP that contains DRSP/EE given to women with prospectively diagnosed PME of depression was effective. Again, the possible effects of OCPs on women with an underlying mood disorder need to be considered.

Among the most effective hormonal treatments for PMS suppression is the gonadotropin-releasing hormone (GnRH) agonist leuprolide, which is administered by monthly injection in depot form, and intranasal buserelin(Drug information on buserelin). GnRH agonists decrease pituitary release of follicle-stimulating hormone and luteinizing hormone, thereby suppressing ovulation. One key note about the treatment of comorbid depression and PMDD is that the GnRH agonists are less effective when there is an underlying depressive disorder.³² In addition, GnRH agonists can be difficult for patients because of the resulting hypoestrogenism. Adverse effects of GnRH treatment include hot flashes, headaches, and osteoporosis.

Grigorova and colleagues³³reported a significant increase in Beck Depression Inventory scores in 26 previously asymptomatic women after 4 weeks of treatment with leuprolide. The mood-related adverse effects of a GnRH agonist should be monitored closely in all women; this is especially important in women who are predisposed to mood disorders.

Calcium

Calcium carbonate reduces premenstrual depression, fatigue, edema, and pain significantly more than placebo in women with PMS.³⁴Although there are no data in women with Axis I comorbidity and PMDD, calcium is a reasonable first-line choice for women with mild PMS symptoms or as an adjunct for women with moderate to severe PMS. Calcium should be used carefully in patients with constipation or renal stones.

Table 2 describes the steps to diagnose PMDD or PME in the context of another psychiatric disorder.

Conclusion

In patients with PMDD there is a 30% to 70% and a 14% to 16% lifetime risk of major depression and anxiety, respectively. Patients with PMDD need to be screened for depression and anxiety and vice versa. There are few data to guide treatment in these patients, but the use of SSRIs should be considered first-line with various dosing strategies to increase effectiveness.

Pages: 1 2

References

1. Yonkers KA, O’Brien PM, Eriksson E. Premenstrual syndrome. Lancet. 2008;371:1200-1210.
2. Wittchen HU, Becker E, Lieb R, Krause P. Prevalence, incidence and stability of premenstrual dysphoric disorder in the community. Psychol Med. 2002;32:119-132.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.
4. Pearlstein TB, Halbreich U, Batzar ED, et al. Psychosocial functioning in women with premenstrual dysphoric disorder before and after treatment with sertraline or placebo. J Clin Psychiatry. 2000;61:101-109.
5. Kornstein SG, Harvey AT, Rush AJ, et al. Self-reported premenstrual exacerbation of depressive symptoms in patients seeking treatment for major depression. Psychol Med. 2005;35:683-692.
6. Kim DR, Gyulai L, Freeman EW, et al. Premenstrual dysphoric disorder and psychiatric co-morbidity. Arch Womens Ment Health. 2004;7:37-47.
7. Adewuya AO, Loto OM, Adewumi TA. Premenstrual dysphoric disorder amongst Nigerian university students: prevalence, comorbid conditions, and correlates. Arch Womens Ment Health. 2008;11:13-18.
8. Cohen LS, Soares CN, Otto MW, et al. Prevalence and predictors of premenstrual dysphoric disorder (PMDD) in older premenopausal women. The Harvard Study of Moods and Cycles. J Affect Disord. 2002;70: 125-132.
9. Yonkers KA, Pearlstein T, Rosenheck RA. Premenstrual disorders: bridging research and clinical reality. Arch Womens Ment Health. 2003;6:287-292.
10. Bloch M, Rotenberg N, Koren D, Klein E. Risk factors associated with the development of postpartum mood disorders. J Affect Disord. 2005;88:9-18.
11. Maskall DD, Lam RW, Misri S, et al. Seasonality of symptoms in women with late luteal phase dysphoric disorder. Am J Psychiatry. 1997;154:1436-1441.
12. Praschak-Rieder N, Willeit M, Neumeister A, et al. Prevalence of premenstrual dysphoric disorder in female patients with seasonal affective disorder. J Affect Disord. 2001;63:239-242.
13. Praschak-Rieder N, Willeit M, Winkler D, et al. Role of family history and 5-HTTLPR polymorphism in female seasonal affective disorder patients with and without premenstrual dysphoric disorder. Eur Neuropsychopharmacol. 2002;12:129-134.
14. Rapkin AJ, Edelmuth E, Chang LC, et al. Whole-blood serotonin in premenstrual syndrome. Obstet Gynecol. 1987;70:533-537.
15. Rojansky N, Halbreich U, Zander K, et al. Imipramine receptor binding and serotonin uptake in platelets of women with premenstrual changes. Gynecol Obstet Invest. 1991;31:146-152.
16. Taylor DL, Mathew RJ, Ho BT, Weinman ML. Serotonin levels and platelet uptake during premenstrual tension. Neuropsychobiology. 1984;12:16-18.
17. Menkes DB, Coates DC, Fawcett JP. Acute tryptophan depletion aggravates premenstrual syndrome. J Affect Disord. 1994;32:37-44.
18. Ho HP, Olsson M, Westberg L, et al. The serotonin reuptake inhibitor fluoxetine reduces sex steroid-related aggression in female rats: an animal model of premenstrual irritability? Neuropsychopharmacology. 2001;24:502-510.
19. Steiner M, Pearlstein T, Cohen LS, et al. Expert guidelines for the treatment of severe PMS, PMDD, and comorbidities: the role of SSRIs. J Womens Health (Larchmt). 2006;15:57-69.
20. Golding JM, Taylor DL, Menard L, King MJ. Prevalence of sexual abuse history in a sample of women seeking treatment for premenstrual syndrome. J Psychosom Obstet Gynaecol. 2000;21:69-80.
21. Perkonigg A, Yonkers KA, Pfister H, et al. Risk factors for premenstrual dysphoric disorder in a community sample of young women: the role of traumatic events and posttraumatic stress disorder. J Clin Psychiatry. 2004;65:1314-1322.
22. Gorman JM, Kent J, Martinez J, et al. Physiological changes during carbon dioxide inhalation in patients with panic disorder, major depression, and premenstrual dysphoric disorder: evidence for a central fear mechanism. Arch Gen Psychiatry. 2001;58:125-131.
23. Epperson CN, Haga K, Mason GF, et al. Cortical gamma-aminobutyric acid levels across the menstrual cycle in healthy women and those with premenstrual dysphoric disorder: a proton magnetic resonance spectroscopy study. Arch Gen Psychiatry. 2002;59:851-858.
24. Halbreich U, Petty F, Yonkers K, et al. Low plasma gamma-aminobutyric acid levels during the late luteal phase of women with premenstrual dysphoric disorder. Am J Psychiatry. 1996;153:718-720.
25. Freeman EW, DeRubeis RJ, Rickels K. Reliability and validity of a daily diary for premenstrual syndrome. Psychiatry Res. 1996;65:97-106.
26. Miller MN, Newell CL, Miller BE, et al. Variable dosing of sertraline for premenstrual exacerbation of depression: a pilot study. J Womens Health (Larchmt). 2008;17:993-997.
27. Yonkers KA, White K. Premenstrual exacerbation of depression: one process or two? J Clin Psychiatry. 1992;53:289-292.
28. Alpay FB, Turhan NO. Intermittent versus continuous sertraline therapy in the treatment of premenstrual dysphoric disorders. Int J Fertil Womens Med. 2001;46:228-231.
29. Berger CP, Presser B. Alprazolam in the treatment of two subsamples of patients with late luteal phase dysphoric disorder: a double-blind, placebo-controlled crossover study. Obstet Gynecol. 1994;84:379-385.
30. Young EA, Kornstein SG, Harvey AT, et al. Influences of hormone-based contraception on depressive symptoms in premenopausal women with major depression. Psychoneuroendocrinology. 2007;32:843-853.
31. Joffe H, Petrillo LF, Viguera AC, et al. Treatment of premenstrual worsening of depression with adjunctive oral contraceptive pills: a preliminary report. J Clin Psychiatry. 2007;68:1954-1962.
32. Freeman EW, Sondheimer SJ, Rickels K. Gonadotropin-releasing hormone agonist in the treatment of premenstrual symptoms with and without ongoing dysphoria: a controlled study. Psychopharmacol Bull. 1997;33:303-309.
33. Grigorova M, Sherwin BB, Tulandi T. Effects of treatment with leuprolide acetate depot on working memory and executive functions in young premenopausal women. Psychoneuroendocrinology. 2006;31:935-947.
34. Thys-Jacobs S, Starkey P, Bernstein D, Tian J. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol. 1998;179:444-452.

FROM PHYSICIANS PRACTICE

Five Steps to Improving Patient Access
Judy Capko, May 21, 2013
Patient access is getting increased attention through reform initiatives. Here are five steps you can take to make sure patients get appropriate access to care in your office.

Growing HIPAA Threat – Ignore Windows XP at Your Own Peril
Marion K. Jenkins, May 21, 2013
Chances are good that you have some major ticking software time bombs lurking in your medical practice's computer environment, namely Windows XP and Server 2003.

Finding Physician Work-Life Balance in the Small Moments
Jennifer Frank, MD, May 21, 2013
At my practice and at home, things are always busy. There's laundry or homework, or a patient with needs.

Three Areas to Reduce Costs at Your Medical Practice
Greg Mertz, May 19, 2013
By taking a hard look at reducing costs for staffing, overhead, and technology at your medical practice, you may see increased physician compensation.

Dos and Don’ts for Starting a Physician Blog
Michael Woo-Ming, MD, May 18, 2013
Starting a physician blog can provide your medical practice with marketing benefits, but it's important to do it right.

Premenstrual Dysphoric Disorder and Psychiatric Comorbidity

Diagnostic Dilemmas—Effective Treatment Approaches

Join the Conversation