Dysthymia

BALTIMORE -- Intermittent treatment with fluoxetine each month can greatly ease a woman's premenstrual dysphoric disorder--but can mean undertreatment if she has major depression.

And such an approach could catapult a woman with unrecognized bipolar disorder into mania, Dr. Karen L. Swartz warned at a mood disorders symposium sponsored by the Depression and Related Affective Disorders Association.

In women with major depressive disorder, bipolar disorder, or dysthymia, the symptoms can worsen during the luteal phase, thereby mimicking PMDD. A woman with any of these mood disorders may present to her psychiatrist, ob.gyn., or primary care provider with the complaint that she feels increased depression, anxiety, and affect lability in the week preceding onset of menses.

"What I see very commonly in my practice is women with ongoing major depressive symptoms that then worsen in the premenstrual period," said Dr. Swartz of the department of psychiatry and behavioral sciences at the Johns Hopkins University, Baltimore.

Physicians are more likely to encounter women with major depression than with PMDD because 15%-20% of women have major depression at some time in their lives while only 3%-5% have PMDD, she noted.

A primary care physician can readily do the careful assessment that is needed to distinguish between such mood disorders. An estimated 80% of women of reproductive age have some degree of premenstrual mood changes, so clearly there are not enough psychiatrists to handle their evaluation, Dr. Swartz said.

The best way to evaluate such patients is to have them keep a daily symptom diary for at least 2 months. A woman with PMDD will develop five or more of the symptoms of PMDD during the luteal phase of most menstrual cycles throughout the year, with the symptoms disappearing with menstruation, Dr. Swartz said at the symposium, also sponsored by the university.

The symptoms of PMDD include depressed mood (perhaps with self-deprecating thoughts), marked anxiety! tension, marked affective lability, persistent and marked anger/increased interpersonal conflict, difficulty concentrating, hypersomnia/insomnia, food cravings, and feeling overwhelmed. Despite the overlap with some symptoms of other mood disorders, only PMDD involves breast tenderness, bloating, and headaches, she noted.

Women with luteal-phase exacerbation of major depression, panic disorder, dysthymia, or personality disorder also will report symptoms throughout the month. The symptoms will not disappear with the onset of menses.

The overlap between PMDD and major depression is illustrated by findings from a University of Pittsburgh study of 98 women who reported having had PMDD for 2 months. Interviews with psychiatrists showed that 19 of the women were having a major depressive episode at the time of the study so they were excluded. Of the remaining 78 women, interviews showed that 78% had a history of some psychiatric disorder, 46% had a history of major depression, and 10% had a personality disorder.

Dr. Swartz described a metaanalysis of 15 studies involving a total of 904 women with PMDD. About half were treated with placebo, and the other half received continuous or intermittent treatment with fluoxetine.

Active treatment significantly reduced symptoms, compared with placebo, and intermittent treatment was as effective as continuous treatment.

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