More on SSRIs and Premenstrual Dysphoria
Abstract & Commentary
Source: Pearlstein TB, 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.
Premenstrual dysphoric disorder (pmdd) requires premenstrual impairment in interpersonal and role functioning in addition to documentation of specific symptoms by prospective daily charting and the absence of concurrent disorders that are premenstrually exacerbated. Impaired functioning is a key feature in distinguishing PMDD on the "severe" end of the continuum of emotional, behavioral, and physical symptoms described as premenstrual syndrome (PMS). Few studies have prospectively documented the degree of functional impairment in women with PMDD before and after treatment.
This study was a multicenter, randomized, placebo-controlled trial comparing sertraline and placebo for PMDD at 12 university-affiliated centers in the United States. The study had three phases: screening for two menstrual cycles, single-blind placebo for one menstrual cycle, and placebo nonresponders randomized to flexible dose sertraline (up to 150 mg/d) or placebo for three menstrual cycles. Psychosocial functioning was measured by the Daily Record of Severity of Problems (DRSP; 24 items, with work, social function, and relationship domains), the Social Adjustment Scale Self-Report (SAS; with work, social/leisure, and interpersonal domains), and the short form of the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q). Clinicians also rated the patient using the Hamilton Depression Scale (HAM-D) to screen out major depression. Patients averaged 36 years of age, a 10-year duration of PMDD, and a sertraline dose of 100 mg/d; 33% had a history of major depression. Baseline mild luteal impairment was found on the SAS, though this was significantly worse than a comparable community cohort; no differences between the sertraline and placebo groups occurred according to the DRSP, SAS, and Q-LES-Q.
The total, work, social/leisure, marital, and family SAS domain scores showed significantly greater improvement with sertraline compared with placebo (only) at end point. Functional improvement on the SAS appeared to be significantly predicted by baseline DSRP and Q-LES-Q scores, as well as HAM-D scores. Pearlstein and colleagues conclude that although psychological and physical symptoms may resolve quickly, PMDD includes recurrent, cyclical symptoms on social relationships and roles that may take more than one menstrual cycle to resolve. In comparison with other studies, it appears that PMDD and PMS may have a differentially greater effect on marital and parental roles and the ability to enjoy pleasurable activities than work roles. The study is limited only by the lack of a clinician-rated quality of life and functioning.
Comment by Donald m. Hilty, MD
This is an exciting time in the evaluation and treatment of symptoms of PMDD and PMS, according to the literature. Individual cognitive therapy was superior to wait-list control in improving social functioning in 23 patients with PMS.1 A study of 320 patients reported that fluoxetine at 20 or 60 mg/d was superior to placebo in improving the social impairment scale on the Premenstrual Tension Symptom Scale.2 Sertraline was better than placebo for PMDD symptoms in a multicenter, randomized trial3 and better than desipramine or placebo in improving quality of life on self-report measures in 167 patients with PMS or PMDD.4 Self-report measures are a practical way to track progress and more studies are needed to validate these scales compared to clinician ratings. Physical symptomatic improvement appears to precede quality of life improvement for these patients, and studies extending 3-6 months may be indicated.
References
1. Blake F, et al. Cognitive therapy for premenstrual syndrome: A controlled trial. J Psychosom Res 1998; 45:307-318.
2. Steiner M, et al. Fluoxetine’s efficacy in improving premenstrual dysphoric disorder. In: New Research Program and Abstracts of the 152nd Annual Meeting of the American Psychiatric Association; May 19, 1999; Washington, DC. Abstract NR569:227.
3. Freeman EW, et al. Differential response to antidepressants in women with premenstrual syndrome/premenstrual dysphoric disorder: A randomized controlled trial. Arch Gen Psychiatry 1999;56:932-939.
4. Yonkers KA, et al. Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. A randomized controlled trial. JAMA 1997; 278:983-988.
In the Pearlstein study of PMDD, quality-of-life measures showed a difference between the sertraline and placebo groups at what period?
a. Baseline
b. 1 month
c. 2 months
d. 3 months
e. Never
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