- Email: [email protected]
Personal history of major depression may put women at risk for premenstrual dysphoric symptomatology
Journal of Affective Disorders 150 (2013) 1234–1237
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Brief report
Personal history of major depression may put women at risk for premenstrual dysphoric symptomatology Eynav E. Accortt a,n, Anya V. Kogan b, John J.B. Allen b,nn a b
Department of Psychology, University of California, Los Angeles, 1285 Franz Hall, Box 951563, Los Angeles, CA 90095-1563, USA University of Arizona, Tucson, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 20 May 2013 Accepted 31 May 2013 Available online 22 June 2013
Background: Premenstrual dysphoric disorder (PMDD) is a chronic condition that significantly affects a woman's well-being on a monthly basis. Although co-occurrence of PMDD and major depressive disorder (MDD) is common, most studies examine whether women with PMDD are at risk for depression and investigations of PMDD in depressed women are scant. Therefore, the present study examined rates of PMDD in young depressed women. Methods: PMDD was assessed using a structured clinical interview (SCID-PMDD) in a sample of 164 young women with (n ¼ 85) and without (n ¼79) any history of depression. Results: Rates of PMDD were elevated among women with MDD in this sample. This result held true regardless of participants' MDD status (current, lifetime or past history-only symptoms of MDD) and regardless of whether all or most DSM-IV-TR PMDD criteria were met. Limitations: Sample size in the present study was relatively small, and daily diary data were not available to confirm a PMDD diagnosis. Conclusions: The current study highlights the need for clinicians to assess for PMDD in young female patients with major depression. Depressed women experiencing the added physical and psychological burden of PMDD may have a more severe disease course, and future studies will need to identify appropriate treatments for this subset of depressed women. Published by Elsevier B.V.
Keywords: Premenstrual dysphoric disorder Major depressive disorder Comorbidity
1. Background Premenstrual dysphoric disorder (PMDD) is a chronic condition that significantly affects well-being during the reproductive years. The pattern of symptoms of PMDD is linked to the menstrual cycle, with the onset of symptoms in the late luteal phase and the symptom offset shortly after the beginning of menses (Freeman, 2004). PMDD is currently classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-4th ed.; American Psychiatric Association (APA), 2000) as a depressive disorder not otherwise specified, and based on existing research evidence, the Mood Disorders Work Group for DSM-5 proposed to move PMDD to the position of a full-category in DSM-5 (Epperson et al., 2012). Based on DSM-IV criteria, at least five of 11 symptoms are necessary for diagnosis, with at least one of the symptoms being related to mood. Symptoms include depressed mood, anxiety/ tension, affective lability, anger/irritability, decreased interest,
n
Corresponding author. Tel.: +1 310 825 2248. Correspondence to: Department of Psychology, University of Arizona, 1503 E. University Avenue, Room 312, Tucson, AZ 85721-0068, USA. E-mail addresses: [email protected] (E.E. Accortt), [email protected] (J.J.B. Allen). nn
0165-0327/$ - see front matter Published by Elsevier B.V. http://dx.doi.org/10.1016/j.jad.2013.05.091
difficulty concentrating, fatigue, appetite changes, sleep difficulties, feeling out of control and physical symptoms (APA, 2000). PMDD is associated with significant personal and economic costs, increased work absenteeism, reduced work productivity (Heinemann et al., 2012), and reduced quality of life (Heinemann et al., 2010; Yang et al., 2008, 2010). Sex differences in depression rates (Sprock and Yoder, 1997; Wolk and Weissman, 1995) suggest that women might be at increased risk for psychiatric illnesses as a result of naturally changing hormonal levels during their reproductive cycle (Miller et al., 2009). In addition to high rates of pregnancy, post-partum, and peri-menopausal depression (Soares and Zitek, 2008), up to 85% of menstruating women exhibit one or more menstrual cyclerelated symptom, 20–40% report Premenstrual Syndrome (PMS), and 2–9% report PMDD (Clayton, 2008). The comorbidity rates between major depressive disorder (MDD) and PMDD are high, spanning a range of 30–70% (Endicott, 1994). Both MDD (Kendler et al., 2006) and PMDD (Treloar et al., 2002) have heritable risk, suggesting the possibility that both PMDD and MDD share common risk mechanisms (Accortt and Allen, 2006; Accortt et al., 2011b). Despite a significant overlap in symptoms between PMDD and MDD, the monthly recurrent and predictable pattern of symptom
E.E. Accortt et al. / Journal of Affective Disorders 150 (2013) 1234–1237
onset and offset is a key feature that distinguishes PMDD from other mood disorders (Endicott et al., 1999). Women with PMDD are also more likely to report physical symptoms such as bloating and breast tenderness (Di Giulio and Reissing, 2006; Hartlage et al., 2012) and irritability (Angst et al., 2001; Landen and Eriksson, 2003) as opposed to depressed mood (Bhatia and Bhatia, 2002). Additionally, treatment response to medications differs as women with PMDD report alleviation of symptoms almost immediately after administration of the serotonin reuptake inhibitors (SRIs; Steiner et al., 2005, 2008; Yonkers et al., 2006). To date, a majority of studies have focused on whether women with PMDD are at risk for depression (Endicott and Halbreich, 1988; Pearlstein et al., 1990; Yonkers et al., 1997). There are very few investigations of the prevalence of premenstrual symptoms in depressed women (Halbreich and Endicott, 1985; Hsiao et al., 2004; Miyaoka et al., 2011), none of which provided interviewbased assessments of PMDD. To address this gap, the present study examined rates of PMDD in a sample of young depressed women. Examining PMDD in the context of depression is important as these women may experience a more severe course of illness (Pilver et al., 2013) and have unique characteristics that influence treatment response.
2. Methods 2.1. Participant selection Participants with and without MDD were recruited in a larger study of depression (Stewart et al., 2010). All female subjects were assessed to determine PMDD status using a structured clinical interview (Accortt et al., 2011a). Participants with disorders other than PMDD, MDD, and dysthymia were excluded, as were any using prescription and psychotropic medications (see Accortt et al. (2011b) for full exclusion criteria). Intake interviews with eligible participants were conducted by graduate-level clinicians, who administered the Hamilton Depression Rating Scale (HDRS; Hamilton, 1967), Structured Clinical Interview for the DSM-IV (SCID; First et al., 1997), and SCID-PMDD. The SCID-PMDD is a reliable structured PMDD interview created from the DSM-IV-TR PMDD criteria, modeled after the SCID format (see Accortt et al. (2011a) for description and psychometric properties).
1235
Table 1 Demographic information.
N subjects Mean age % HBC % With Dysthymia % With Lifetime MDD Mean HRSD Mean # PMDD Symptomsn Race percentage Caucasian (%) Other (%) Asian (%) Black (%) Am. Indian (%) More than one (%) No response (%)
Entire sample
PMDD symptomatology
164 18.8 7 1.2 36.6 5.5 52 8.0 7 6.9 2.2 7 2.6
25 18.9 7 1.4 40 8.0 80 12.2 77.0 6.8 71.7
73.8 9.1 5.5 3.7 3.7 0.6 3.7
84 4 8 4
Unless marked with an asterisk, no significant differences between these groups were found. Note: PMDD¼ premenstrual dysphoric disorder. MDD ¼major depressive disorder. HBC¼ hormonal birth control. HRSD ¼Hamilton Rating Scale for Depression. Means are shown 7standard deviations. n
p o 0.01.
the entire sample) met DSM-IV-TR criteria for PMDD, endorsing five or more of the DSM-IV-TR items with symptoms that lasted four or more days. Twelve participants (7% of the entire sample) endorsed five or more of the DSM-IV-TR items, but did not fully meet the time specification criteria listed in the DSM-IV-TR because their symptoms lasted less than four days. These 12 women, together with the women meeting the strict criteria (totaling 25 participants), were classified as Spectrum PMDD. Participants were categorized in terms of MDD (lifetime and current) using the SCID. It is worth noting that the Mood Disorders Work Group for DSM-5 proposed revising the timing criterion such that symptoms need not be present for most of the week prior to the onset of menses, instead allowing the presence of symptoms during any point that week to be sufficient (Epperson et al., 2012). Under the proposed revised criteria, both Strict PMDD and Spectrum PMDD women in the present study would be diagnosed with PMDD.
2.2. Population details
3. Results
Out of 177 women recruited between 2004 and 2007, 7 women dropped out of the study, 6 women did not complete the PMDD interview for various reasons, resulting in 164 women included in this study. All participants were university undergraduate students with an average age of 18.9 years (7 1.2 s.d., range of 18–25). Table 1 presents demographic and birth control status details for the sample by diagnostic status. Use of birth control pills (BCP) was unrelated to PMDD status (see Table 1).
PMDD prevalence was 8% for the Strict PMDD classification (13/164), and an additional 7% (12/164) met DSM-IV-TR criteria for PMDD (including the impairment criterion) but symptoms did not last “most of the week,” totaling 15% who were thus considered among the Spectrum PMDD classification.
2.3. Participant grouping Thirty women endorsing sufficient premenstrual symptoms were invited to participate in the daily diary monitoring (Daily Record of Severity of Problems, DRSP; Endicott et al., 2006). Because participants were not compensated for their participation, compliance was poor, and conclusive evidence of two consecutive cycles with late luteal phase mood worsening was not available. Five participants in whom partial diary data were able to disconfirm at least one cycle of late luteal mood worsening were removed from the PMDD experimental group. In the remaining group of 25 interview identified participants, 13 participants (8% of
3.1. Co-occurrence of diagnoses The co-occurrence of MDD and PMDD was examined to determine if any history of MDD was associated with elevated rates of PMDD. To characterize the co-occurrence of PMDD classification and major depression status, a series of Chi Square tests were carried out to test the independence of PMDD classification and MDD status. Analyses were run separately for classifications of Strict PMDD (13 PMDD+ and 151 PMDD−) and Spectrum PMDD (25 PMDD+, 139 PMDD−), and also separately for Current MDD (37 MDD+, 127 MDD−), and participants with any History of depression (current or past MDD status) called Lifetime MDD status (85 MDD+, 79 MDD−). Moreover, to assess whether there was an increased likelihood of PMDD in women with past history of MDD, unconfounded by current MDD or dysthymia
1236
E.E. Accortt et al. / Journal of Affective Disorders 150 (2013) 1234–1237
Fig. 1. Prevalence of PMDD as a function of MDD status. Spectrum PMDD diagnosis is consistent with proposed DSM-5 criteria for PMDD, whereas Strict PMDD diagnosis reflects the additional stipulation in DSM-IV that symptoms last a majority of the week.
symptoms that could account for the overlap, the rates of PMDD were compared between never depressed women (79 Lifetime MDD−) and euthymic women with past history of MDD (45 Euthymic MDD Hx+). For this last analysis, 13 of the 25 Spectrum PMDD cases remained and six of the 13 Strict PMDD cases remained in the analyses. Fig. 1 shows that in general terms, MDD diagnoses are associated with a higher likelihood of PMDD diagnoses. Significant relationships emerged between Lifetime MDD and Strict PMDD (χ2 (1, N ¼ 164) ¼9.3, p o0.05), Current MDD and Strict PMDD (χ2 (1, N ¼ 164) ¼7.9, p o0.05), and currently euthymic women and Strict PMDD (χ2 (1, N ¼127) ¼6.1, p o0.05). In each case, MDD women had a higher rate of PMDD than non MDD women. Significant relationships also emerged between Lifetime MDD and Spectrum PMDD (χ2 (1, N ¼164) ¼ 9.4, po 0.05), Current MDD and Spectrum PMDD (χ2 (1, N ¼164) ¼7.8, p o0.05) and currently euthymic women and Strict PMDD (χ2 (1, N ¼123) ¼4.0, po 0.05). In each case, MDD women had a higher rate of PMDD than non MDD women. Therefore, regardless of whether MDD was defined in terms of current, lifetime, or past-history only status, for both Strict and Spectrum PMDD classifications, rates of PMDD were elevated among women with MDD in this sample.
4. Discussion Extending previous findings on co-occurrence of MDD and PMDD, this study found that college-age women with MDD tend to have elevated rates of PMDD. Increased prevalence of PMDD was consistent across depression diagnoses (Current, Lifetime, and Euthymic Hx+) for women meeting Strict PMDD criteria as well as for women meeting all of the DSM-IV-TR criteria except for timing of symptoms. These findings refute the possibility that currently depressed women are simply endorsing premenstrual symptoms due to current depressive symptoms (i.e., “I feel depressed, so ‘everything’ is wrong with me”) as women positive for history of depression but currently not experiencing MDD (Euthymic MDD Hx+) had rates of PMDD that were elevated compared to never depressed women. These findings are consistent with the questionnaire-based reports of elevated rates of PMDD in depressed women in Japan (Miyaoka et al., 2011), although the prevalence rates in the present study are somewhat lower, as might be expected from the use of a structured interview. The present results suggest that PMDD prevalence is relatively high among those with any history of MDD. Therefore, MDD patients should be carefully assessed for PMDD. This is especially important for treatment considerations (Epperson et al., 2012), as depressed women with greater premenstrual symptoms have a
more severe disease course (Hartlage et al., 2004), including an elevated risk for non-fatal suicidal behaviors (Pilver et al., 2013). Having comorbid PMDD and MDD may potentially increase the severity of suicidal symptoms and subsequently, the likelihood of suicide attempts. The age of participants in this study is 18–25 years, so these women have not had a long period of risk for either MDD or PMDD. As an early-onset sample, these women may have more lifetime mood instability and more lifetime episodes than those with later onset, and therefore, may endure the emotional burden of mood fluctuations for a significant portion of their lives. For these reasons it is imperative to begin investigating symptomatology, course and risk for PMDD (and other mood disorders) at an earlier age. 4.1. Strengths, limitations, and future directions Limitations of the present study are a relatively small sample of women and unavailability of 2 months of diary data to confirm the PMDD diagnosis. Nonetheless, this study represents an advance over self-report studies by providing a reliable structured interview diagnosis for women with PMDD (Accortt et al., 2011a). Future studies with incentives for diary completion will be needed to determine what percentage of women meeting PMDD criteria according to the interview are confirmed with diary data. Even in the absence of the diary data, the current study provides clinically relevant information on elevated rates of PMDD symptoms in young women with an early onset of depressive diagnoses, and underscores the need for clinicians to assess for PMDD in young female MDD patients. Further investigations of PMDD in women with mood disorders will help identify appropriate treatments for those experiencing the added significant psychological and physical burden of PMDD in addition to the existing mood instability associated with other mood disorders.
Role of funding source The funding source (NIH) had no role in study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the paper for publication.
Conflict of interest The authors have no conflict of interest to report.
Acknowledgments This research was supported in part by grants from the National Institutes of Health (R01-MH066902) and the National Alliance for Research on Schizophrenia and Depression (NARSAD) to John Allen. The authors wish to thank Eliza Fergerson, Jamie Velo, Dara Halpern, Craig Santerre, Amanda Brody, Jay Hegde and many research assistants for their help on this project.
E.E. Accortt et al. / Journal of Affective Disorders 150 (2013) 1234–1237
References Accortt, E.E., Allen, J.J.B., 2006. Frontal EEG asymmetry and premenstrual dysphoric symptomatology. Journal of Abnormal Psychology 1, 179–184. Accortt, E.E., Bismark, A., Schneider, T.R., Allen, J.J.B., 2011a. Diagnosing premenstrual dysphoric disorder: the reliability of a structured clinical interview. Archives of Women's Mental Health 14 (3), 265–267. Accortt, E.E., Stewart, J.L., Coan, J.A., Manber, R., Allen, J.J.B., 2011b. Prefrontal brain asymmetry and pre-menstrual dysphoric disorder symptomatology. Journal of Affective Disorders 28 (1–2), 178–183. American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision American Psychiatric Association, Washington, DC. Angst, J., Sellaro, R., Merikangas, K.R., Endicott, J., 2001. The epidemiology of perimenstrual psychological symptoms. Acta Psychiatrica Scandinavica 104 (2), 110–116. Bhatia, S.C., Bhatia, S.K., 2002. Diagnosis and treatment of premenstrual dysphoric disorder. American Family Physician 66 (7), 1239–1248. Clayton, A.H., 2008. Symptoms related to the menstrual cycle: diagnosis, prevalence, and treatment. Journal of Psychiatric Practice 14 (1), 13–21. Di Giulio, G., Reissing, E.D., 2006. Premenstrual dysphoric disorder: prevalence, diagnostic considerations, and controversies. Journal of Psychosomatic Obstetrics & Gynecology 27 (4), 201–210. Endicott, J., 1994. Differential diagnosis and comorbidity. In: Gold, J.H., Severino, S. K. (Eds.), Premenstrual Dysphoria: Women's Reality. APA Press, Washington, DC. Endicott, J., Amsterdam, J., Eriksson, E., Frank, E., Freeman, E., Hirschfeld, R., Ling, F., Parry, B., Pearlstein, T., Rosenbaum, J., Rubinow, D., Schmidt, P., Severino, S., Steiner, M., Stewart, D.E., Thys-Jacobs, S., 1999. Is premenstrual dysphoric disorder a distinct clinical entity? Journal of Women's Health & Gender-Based Medicine 8 (5), 663–679. Endicott, J., Halbreich, U., 1988. Clinical significance of premenstrual dysphoric changes. Journal of Clinical Psychiatry 49 (12), 486–489. Endicott, J., Nee, J., Harrison, W., 2006. Daily record of severity of problems (DRSP): reliability and validity. Archives of Women's Mental Health 9 (1), 41–49. Epperson, C.N., Steiner, M., Hartlage, S.A., Eriksson, E., Schmidt, P.J., Jones, I., Yonkers, K.A., 2012. Premenstrual dysphoric disorder: evidence for a new category for DSM-5. American Journal of Psychiatry 169 (5), 465–475. First, M.G., Spitzer, R.L., Gibbon, M., Williams, J.B., 1997. Structured Clinical Interview for DSM-IV Axis I Disorder—Clinical Version, Administration Booklet. Biometrics Research Department, New York, NY. Freeman, E.W., 2004. Luteal phase administration of agents for the treatment of premenstrual dysphoric disorder. CNS Drugs 18, 453–468. Halbreich, U., Endicott, J., 1985. Relationship of dysphoric premenstrual changes to depressive disorders. Acta Psychiatrica Scandinavica 71 (4), 331–338. Hamilton, M., 1967. Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology 6 (4), 278–296. Hartlage, S.A., Brandenburg, D.L., Kravitz, H.M., 2004. Premenstrual exacerbation of depressive disorders in a community-based sample in the United States. Psychosomatic Medicine 66 (5), 698–706. Hartlage, S.A., Freels, S., Gotman, N., Yonkers, K., 2012. Criteria for premenstrual dysphoric disorder: secondary analyses of relevant data sets. Archives of General Psychiatry 69 (3), 300–305. Heinemann, L.A., Do Minh, T., Filonenko, A., Uhl-Hochgraber, K., 2010. Explorative evaluation of the impact of premenstrual disorder on daily functioning and quality of life. Patient 3 (2), 125–132. Heinemann, L.A., Minh, T.D., Heinemann, K., Lindemann, M., Filonenko, A., 2012. Intercountry assessment of the impact of severe premenstrual disorders on work and daily activities. Health Care for Women International 33 (2), 109–124.
1237
Hsiao, M.C., Hsiao, C.C., Liu, C.Y., 2004. Premenstrual symptoms and premenstrual exacerbation in patients with psychiatric disorders. Psychiatry and Clinical Neurosciences 58 (2), 186–190. Kendler, K.S., Gatz, M., Gardner, C.O., Pedersen, N.L., 2006. A Swedish national twin study of lifetime major depression. American Journal of Psychiatry 163 (1), 109–114. Landen, M., Eriksson, E., 2003. How does premenstrual dysphoric disorder relate to depression and anxiety disorders? Depression and Anxiety 17 (3), 122–129. Miller, L.J., Girgis, C., Gupta, R., 2009. Depression and related disorders during the female reproductive cycle. Womens Health 5 (5), 577–587. Miyaoka, Y., Akimoto, Y., Ueda, K., Ujiie, Y., Kametani, M., Uchiide, Y., Kamo, T., 2011. Fulfillment of the premenstrual dysphoric disorder criteria confirmed using a self-rating questionnaire among Japanese women with depressive disorders. Biopsychosocial Medicine 5, 1–8. Pearlstein, T.B., Frank, E., Rivera-Tovar, A., Thoft, J.S., Jacobs, E., Mieczkowski, T.A., 1990. Prevalence of axis I and axis II disorders in women with late luteal phase dysphoric disorder. Journal of Affective Disorders 20 (2), 129–134. Pilver, C.E., Libby, D.J., Hoff, R.A., 2013. Premenstrual dysphoric disorder as a correlate of suicidal ideation, plans, and attempts among a nationally representative sample. Social Psychiatry and Psychiatric Epidemiology 48 (3), 437–446. Soares, C.N., Zitek, B., 2008. Reproductive hormone sensitivity and risk for depression across the female life cycle: a continuum of vulnerability. Journal of Psychiatry and Neuroscience 33 (4), 331–343. Sprock, J., Yoder, C.Y., 1997. Women and depression: an update on the report of the APA task force. Sex Roles 36, 269–303. Steiner, M., Hirschberg, A.L., Bergeron, R., Holland, F., Gee, M.D., Van Erp, E., 2005. Luteal phase dosing with paroxetine controlled release (CR) in the treatment of premenstrual dysphoric disorder. American Journal of Obstetrics and Gynecology 193 (2), 352–360. Steiner, M., Ravindran, A.V., LeMelledo, J.M., Carter, D., Huang, J.O., Anonychuk, A.M., Simpson, S.D., 2008. Luteal phase administration of paroxetine for the treatment of premenstrual dysphoric disorder: a randomized, double-blind, placebocontrolled trial in Canadian women. Journal of Clinical Psychiatry 69 (6), 991–998. Stewart, J.L., Bismark, A.W., Towers, D.N., Coan, J.A., Allen, J.J.B., 2010. Resting frontal EEG asymmetry as an endophenotype for depression risk: sex-specific patterns of frontal brain asymmetry. Journal of Abnormal Psychology 119 (3), 502–512. Treloar, S.A., Heath, A.C., Martin, N.G., 2002. Genetic and environmental influences on premenstrual symptoms in an Australian twin sample. Psychological Medicine 32 (1), 25–38. Wolk, S.I., Weissman, M.M., 1995. Women and depression: an update. Review of Psychiatry 14, 227–259. Yang, M., Gricar, J.A., Maruish, M.E., Hagan, M.A., Kornstein, S.G., Wallenstein, G.V., 2010. Interpreting Premenstrual Symptoms Impact Survey scores using outcomes in health-related quality of life and sexual drive impact. Journal of Reproductive Medicine 55 (1–2), 41–48. Yang, M., Wallenstein, G., Hagan, M., Guo, A., Chang, J., Kornstein, S., 2008. Burden of premenstrual dysphoric disorder on health-related quality of life. Journal of Women's Health 17 (1), 113–121. Yonkers, K.A., Halbreich, U., Freeman, E., Brown, C., Endicott, J., Frank, E., Parry, B., Pearlstein, T., Severino, S., Stout, A., Stone, A., Harrison, W., 1997. Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. A randomized controlled trial. Sertraline Premenstrual Dysphoric Collaborative Study Group 278 (12), 983–988. Journal of American Medical Association 278 (12), 983–988. Yonkers, K.A., Holthausen, G.A., Poschman, K., Howell, H.B., 2006. Symptom-onset treatment for women with premenstrual dysphoric disorder. Journal of Clinical Psychopharmacology 26 (2), 198–202.
Contents lists available at ScienceDirect
Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad
Brief report
Personal history of major depression may put women at risk for premenstrual dysphoric symptomatology Eynav E. Accortt a,n, Anya V. Kogan b, John J.B. Allen b,nn a b
Department of Psychology, University of California, Los Angeles, 1285 Franz Hall, Box 951563, Los Angeles, CA 90095-1563, USA University of Arizona, Tucson, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 20 May 2013 Accepted 31 May 2013 Available online 22 June 2013
Background: Premenstrual dysphoric disorder (PMDD) is a chronic condition that significantly affects a woman's well-being on a monthly basis. Although co-occurrence of PMDD and major depressive disorder (MDD) is common, most studies examine whether women with PMDD are at risk for depression and investigations of PMDD in depressed women are scant. Therefore, the present study examined rates of PMDD in young depressed women. Methods: PMDD was assessed using a structured clinical interview (SCID-PMDD) in a sample of 164 young women with (n ¼ 85) and without (n ¼79) any history of depression. Results: Rates of PMDD were elevated among women with MDD in this sample. This result held true regardless of participants' MDD status (current, lifetime or past history-only symptoms of MDD) and regardless of whether all or most DSM-IV-TR PMDD criteria were met. Limitations: Sample size in the present study was relatively small, and daily diary data were not available to confirm a PMDD diagnosis. Conclusions: The current study highlights the need for clinicians to assess for PMDD in young female patients with major depression. Depressed women experiencing the added physical and psychological burden of PMDD may have a more severe disease course, and future studies will need to identify appropriate treatments for this subset of depressed women. Published by Elsevier B.V.
Keywords: Premenstrual dysphoric disorder Major depressive disorder Comorbidity
1. Background Premenstrual dysphoric disorder (PMDD) is a chronic condition that significantly affects well-being during the reproductive years. The pattern of symptoms of PMDD is linked to the menstrual cycle, with the onset of symptoms in the late luteal phase and the symptom offset shortly after the beginning of menses (Freeman, 2004). PMDD is currently classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-4th ed.; American Psychiatric Association (APA), 2000) as a depressive disorder not otherwise specified, and based on existing research evidence, the Mood Disorders Work Group for DSM-5 proposed to move PMDD to the position of a full-category in DSM-5 (Epperson et al., 2012). Based on DSM-IV criteria, at least five of 11 symptoms are necessary for diagnosis, with at least one of the symptoms being related to mood. Symptoms include depressed mood, anxiety/ tension, affective lability, anger/irritability, decreased interest,
n
Corresponding author. Tel.: +1 310 825 2248. Correspondence to: Department of Psychology, University of Arizona, 1503 E. University Avenue, Room 312, Tucson, AZ 85721-0068, USA. E-mail addresses: [email protected] (E.E. Accortt), [email protected] (J.J.B. Allen). nn
0165-0327/$ - see front matter Published by Elsevier B.V. http://dx.doi.org/10.1016/j.jad.2013.05.091
difficulty concentrating, fatigue, appetite changes, sleep difficulties, feeling out of control and physical symptoms (APA, 2000). PMDD is associated with significant personal and economic costs, increased work absenteeism, reduced work productivity (Heinemann et al., 2012), and reduced quality of life (Heinemann et al., 2010; Yang et al., 2008, 2010). Sex differences in depression rates (Sprock and Yoder, 1997; Wolk and Weissman, 1995) suggest that women might be at increased risk for psychiatric illnesses as a result of naturally changing hormonal levels during their reproductive cycle (Miller et al., 2009). In addition to high rates of pregnancy, post-partum, and peri-menopausal depression (Soares and Zitek, 2008), up to 85% of menstruating women exhibit one or more menstrual cyclerelated symptom, 20–40% report Premenstrual Syndrome (PMS), and 2–9% report PMDD (Clayton, 2008). The comorbidity rates between major depressive disorder (MDD) and PMDD are high, spanning a range of 30–70% (Endicott, 1994). Both MDD (Kendler et al., 2006) and PMDD (Treloar et al., 2002) have heritable risk, suggesting the possibility that both PMDD and MDD share common risk mechanisms (Accortt and Allen, 2006; Accortt et al., 2011b). Despite a significant overlap in symptoms between PMDD and MDD, the monthly recurrent and predictable pattern of symptom
E.E. Accortt et al. / Journal of Affective Disorders 150 (2013) 1234–1237
onset and offset is a key feature that distinguishes PMDD from other mood disorders (Endicott et al., 1999). Women with PMDD are also more likely to report physical symptoms such as bloating and breast tenderness (Di Giulio and Reissing, 2006; Hartlage et al., 2012) and irritability (Angst et al., 2001; Landen and Eriksson, 2003) as opposed to depressed mood (Bhatia and Bhatia, 2002). Additionally, treatment response to medications differs as women with PMDD report alleviation of symptoms almost immediately after administration of the serotonin reuptake inhibitors (SRIs; Steiner et al., 2005, 2008; Yonkers et al., 2006). To date, a majority of studies have focused on whether women with PMDD are at risk for depression (Endicott and Halbreich, 1988; Pearlstein et al., 1990; Yonkers et al., 1997). There are very few investigations of the prevalence of premenstrual symptoms in depressed women (Halbreich and Endicott, 1985; Hsiao et al., 2004; Miyaoka et al., 2011), none of which provided interviewbased assessments of PMDD. To address this gap, the present study examined rates of PMDD in a sample of young depressed women. Examining PMDD in the context of depression is important as these women may experience a more severe course of illness (Pilver et al., 2013) and have unique characteristics that influence treatment response.
2. Methods 2.1. Participant selection Participants with and without MDD were recruited in a larger study of depression (Stewart et al., 2010). All female subjects were assessed to determine PMDD status using a structured clinical interview (Accortt et al., 2011a). Participants with disorders other than PMDD, MDD, and dysthymia were excluded, as were any using prescription and psychotropic medications (see Accortt et al. (2011b) for full exclusion criteria). Intake interviews with eligible participants were conducted by graduate-level clinicians, who administered the Hamilton Depression Rating Scale (HDRS; Hamilton, 1967), Structured Clinical Interview for the DSM-IV (SCID; First et al., 1997), and SCID-PMDD. The SCID-PMDD is a reliable structured PMDD interview created from the DSM-IV-TR PMDD criteria, modeled after the SCID format (see Accortt et al. (2011a) for description and psychometric properties).
1235
Table 1 Demographic information.
N subjects Mean age % HBC % With Dysthymia % With Lifetime MDD Mean HRSD Mean # PMDD Symptomsn Race percentage Caucasian (%) Other (%) Asian (%) Black (%) Am. Indian (%) More than one (%) No response (%)
Entire sample
PMDD symptomatology
164 18.8 7 1.2 36.6 5.5 52 8.0 7 6.9 2.2 7 2.6
25 18.9 7 1.4 40 8.0 80 12.2 77.0 6.8 71.7
73.8 9.1 5.5 3.7 3.7 0.6 3.7
84 4 8 4
Unless marked with an asterisk, no significant differences between these groups were found. Note: PMDD¼ premenstrual dysphoric disorder. MDD ¼major depressive disorder. HBC¼ hormonal birth control. HRSD ¼Hamilton Rating Scale for Depression. Means are shown 7standard deviations. n
p o 0.01.
the entire sample) met DSM-IV-TR criteria for PMDD, endorsing five or more of the DSM-IV-TR items with symptoms that lasted four or more days. Twelve participants (7% of the entire sample) endorsed five or more of the DSM-IV-TR items, but did not fully meet the time specification criteria listed in the DSM-IV-TR because their symptoms lasted less than four days. These 12 women, together with the women meeting the strict criteria (totaling 25 participants), were classified as Spectrum PMDD. Participants were categorized in terms of MDD (lifetime and current) using the SCID. It is worth noting that the Mood Disorders Work Group for DSM-5 proposed revising the timing criterion such that symptoms need not be present for most of the week prior to the onset of menses, instead allowing the presence of symptoms during any point that week to be sufficient (Epperson et al., 2012). Under the proposed revised criteria, both Strict PMDD and Spectrum PMDD women in the present study would be diagnosed with PMDD.
2.2. Population details
3. Results
Out of 177 women recruited between 2004 and 2007, 7 women dropped out of the study, 6 women did not complete the PMDD interview for various reasons, resulting in 164 women included in this study. All participants were university undergraduate students with an average age of 18.9 years (7 1.2 s.d., range of 18–25). Table 1 presents demographic and birth control status details for the sample by diagnostic status. Use of birth control pills (BCP) was unrelated to PMDD status (see Table 1).
PMDD prevalence was 8% for the Strict PMDD classification (13/164), and an additional 7% (12/164) met DSM-IV-TR criteria for PMDD (including the impairment criterion) but symptoms did not last “most of the week,” totaling 15% who were thus considered among the Spectrum PMDD classification.
2.3. Participant grouping Thirty women endorsing sufficient premenstrual symptoms were invited to participate in the daily diary monitoring (Daily Record of Severity of Problems, DRSP; Endicott et al., 2006). Because participants were not compensated for their participation, compliance was poor, and conclusive evidence of two consecutive cycles with late luteal phase mood worsening was not available. Five participants in whom partial diary data were able to disconfirm at least one cycle of late luteal mood worsening were removed from the PMDD experimental group. In the remaining group of 25 interview identified participants, 13 participants (8% of
3.1. Co-occurrence of diagnoses The co-occurrence of MDD and PMDD was examined to determine if any history of MDD was associated with elevated rates of PMDD. To characterize the co-occurrence of PMDD classification and major depression status, a series of Chi Square tests were carried out to test the independence of PMDD classification and MDD status. Analyses were run separately for classifications of Strict PMDD (13 PMDD+ and 151 PMDD−) and Spectrum PMDD (25 PMDD+, 139 PMDD−), and also separately for Current MDD (37 MDD+, 127 MDD−), and participants with any History of depression (current or past MDD status) called Lifetime MDD status (85 MDD+, 79 MDD−). Moreover, to assess whether there was an increased likelihood of PMDD in women with past history of MDD, unconfounded by current MDD or dysthymia
1236
E.E. Accortt et al. / Journal of Affective Disorders 150 (2013) 1234–1237
Fig. 1. Prevalence of PMDD as a function of MDD status. Spectrum PMDD diagnosis is consistent with proposed DSM-5 criteria for PMDD, whereas Strict PMDD diagnosis reflects the additional stipulation in DSM-IV that symptoms last a majority of the week.
symptoms that could account for the overlap, the rates of PMDD were compared between never depressed women (79 Lifetime MDD−) and euthymic women with past history of MDD (45 Euthymic MDD Hx+). For this last analysis, 13 of the 25 Spectrum PMDD cases remained and six of the 13 Strict PMDD cases remained in the analyses. Fig. 1 shows that in general terms, MDD diagnoses are associated with a higher likelihood of PMDD diagnoses. Significant relationships emerged between Lifetime MDD and Strict PMDD (χ2 (1, N ¼ 164) ¼9.3, p o0.05), Current MDD and Strict PMDD (χ2 (1, N ¼ 164) ¼7.9, p o0.05), and currently euthymic women and Strict PMDD (χ2 (1, N ¼127) ¼6.1, p o0.05). In each case, MDD women had a higher rate of PMDD than non MDD women. Significant relationships also emerged between Lifetime MDD and Spectrum PMDD (χ2 (1, N ¼164) ¼ 9.4, po 0.05), Current MDD and Spectrum PMDD (χ2 (1, N ¼164) ¼7.8, p o0.05) and currently euthymic women and Strict PMDD (χ2 (1, N ¼123) ¼4.0, po 0.05). In each case, MDD women had a higher rate of PMDD than non MDD women. Therefore, regardless of whether MDD was defined in terms of current, lifetime, or past-history only status, for both Strict and Spectrum PMDD classifications, rates of PMDD were elevated among women with MDD in this sample.
4. Discussion Extending previous findings on co-occurrence of MDD and PMDD, this study found that college-age women with MDD tend to have elevated rates of PMDD. Increased prevalence of PMDD was consistent across depression diagnoses (Current, Lifetime, and Euthymic Hx+) for women meeting Strict PMDD criteria as well as for women meeting all of the DSM-IV-TR criteria except for timing of symptoms. These findings refute the possibility that currently depressed women are simply endorsing premenstrual symptoms due to current depressive symptoms (i.e., “I feel depressed, so ‘everything’ is wrong with me”) as women positive for history of depression but currently not experiencing MDD (Euthymic MDD Hx+) had rates of PMDD that were elevated compared to never depressed women. These findings are consistent with the questionnaire-based reports of elevated rates of PMDD in depressed women in Japan (Miyaoka et al., 2011), although the prevalence rates in the present study are somewhat lower, as might be expected from the use of a structured interview. The present results suggest that PMDD prevalence is relatively high among those with any history of MDD. Therefore, MDD patients should be carefully assessed for PMDD. This is especially important for treatment considerations (Epperson et al., 2012), as depressed women with greater premenstrual symptoms have a
more severe disease course (Hartlage et al., 2004), including an elevated risk for non-fatal suicidal behaviors (Pilver et al., 2013). Having comorbid PMDD and MDD may potentially increase the severity of suicidal symptoms and subsequently, the likelihood of suicide attempts. The age of participants in this study is 18–25 years, so these women have not had a long period of risk for either MDD or PMDD. As an early-onset sample, these women may have more lifetime mood instability and more lifetime episodes than those with later onset, and therefore, may endure the emotional burden of mood fluctuations for a significant portion of their lives. For these reasons it is imperative to begin investigating symptomatology, course and risk for PMDD (and other mood disorders) at an earlier age. 4.1. Strengths, limitations, and future directions Limitations of the present study are a relatively small sample of women and unavailability of 2 months of diary data to confirm the PMDD diagnosis. Nonetheless, this study represents an advance over self-report studies by providing a reliable structured interview diagnosis for women with PMDD (Accortt et al., 2011a). Future studies with incentives for diary completion will be needed to determine what percentage of women meeting PMDD criteria according to the interview are confirmed with diary data. Even in the absence of the diary data, the current study provides clinically relevant information on elevated rates of PMDD symptoms in young women with an early onset of depressive diagnoses, and underscores the need for clinicians to assess for PMDD in young female MDD patients. Further investigations of PMDD in women with mood disorders will help identify appropriate treatments for those experiencing the added significant psychological and physical burden of PMDD in addition to the existing mood instability associated with other mood disorders.
Role of funding source The funding source (NIH) had no role in study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the paper for publication.
Conflict of interest The authors have no conflict of interest to report.
Acknowledgments This research was supported in part by grants from the National Institutes of Health (R01-MH066902) and the National Alliance for Research on Schizophrenia and Depression (NARSAD) to John Allen. The authors wish to thank Eliza Fergerson, Jamie Velo, Dara Halpern, Craig Santerre, Amanda Brody, Jay Hegde and many research assistants for their help on this project.
E.E. Accortt et al. / Journal of Affective Disorders 150 (2013) 1234–1237
References Accortt, E.E., Allen, J.J.B., 2006. Frontal EEG asymmetry and premenstrual dysphoric symptomatology. Journal of Abnormal Psychology 1, 179–184. Accortt, E.E., Bismark, A., Schneider, T.R., Allen, J.J.B., 2011a. Diagnosing premenstrual dysphoric disorder: the reliability of a structured clinical interview. Archives of Women's Mental Health 14 (3), 265–267. Accortt, E.E., Stewart, J.L., Coan, J.A., Manber, R., Allen, J.J.B., 2011b. Prefrontal brain asymmetry and pre-menstrual dysphoric disorder symptomatology. Journal of Affective Disorders 28 (1–2), 178–183. American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision American Psychiatric Association, Washington, DC. Angst, J., Sellaro, R., Merikangas, K.R., Endicott, J., 2001. The epidemiology of perimenstrual psychological symptoms. Acta Psychiatrica Scandinavica 104 (2), 110–116. Bhatia, S.C., Bhatia, S.K., 2002. Diagnosis and treatment of premenstrual dysphoric disorder. American Family Physician 66 (7), 1239–1248. Clayton, A.H., 2008. Symptoms related to the menstrual cycle: diagnosis, prevalence, and treatment. Journal of Psychiatric Practice 14 (1), 13–21. Di Giulio, G., Reissing, E.D., 2006. Premenstrual dysphoric disorder: prevalence, diagnostic considerations, and controversies. Journal of Psychosomatic Obstetrics & Gynecology 27 (4), 201–210. Endicott, J., 1994. Differential diagnosis and comorbidity. In: Gold, J.H., Severino, S. K. (Eds.), Premenstrual Dysphoria: Women's Reality. APA Press, Washington, DC. Endicott, J., Amsterdam, J., Eriksson, E., Frank, E., Freeman, E., Hirschfeld, R., Ling, F., Parry, B., Pearlstein, T., Rosenbaum, J., Rubinow, D., Schmidt, P., Severino, S., Steiner, M., Stewart, D.E., Thys-Jacobs, S., 1999. Is premenstrual dysphoric disorder a distinct clinical entity? Journal of Women's Health & Gender-Based Medicine 8 (5), 663–679. Endicott, J., Halbreich, U., 1988. Clinical significance of premenstrual dysphoric changes. Journal of Clinical Psychiatry 49 (12), 486–489. Endicott, J., Nee, J., Harrison, W., 2006. Daily record of severity of problems (DRSP): reliability and validity. Archives of Women's Mental Health 9 (1), 41–49. Epperson, C.N., Steiner, M., Hartlage, S.A., Eriksson, E., Schmidt, P.J., Jones, I., Yonkers, K.A., 2012. Premenstrual dysphoric disorder: evidence for a new category for DSM-5. American Journal of Psychiatry 169 (5), 465–475. First, M.G., Spitzer, R.L., Gibbon, M., Williams, J.B., 1997. Structured Clinical Interview for DSM-IV Axis I Disorder—Clinical Version, Administration Booklet. Biometrics Research Department, New York, NY. Freeman, E.W., 2004. Luteal phase administration of agents for the treatment of premenstrual dysphoric disorder. CNS Drugs 18, 453–468. Halbreich, U., Endicott, J., 1985. Relationship of dysphoric premenstrual changes to depressive disorders. Acta Psychiatrica Scandinavica 71 (4), 331–338. Hamilton, M., 1967. Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology 6 (4), 278–296. Hartlage, S.A., Brandenburg, D.L., Kravitz, H.M., 2004. Premenstrual exacerbation of depressive disorders in a community-based sample in the United States. Psychosomatic Medicine 66 (5), 698–706. Hartlage, S.A., Freels, S., Gotman, N., Yonkers, K., 2012. Criteria for premenstrual dysphoric disorder: secondary analyses of relevant data sets. Archives of General Psychiatry 69 (3), 300–305. Heinemann, L.A., Do Minh, T., Filonenko, A., Uhl-Hochgraber, K., 2010. Explorative evaluation of the impact of premenstrual disorder on daily functioning and quality of life. Patient 3 (2), 125–132. Heinemann, L.A., Minh, T.D., Heinemann, K., Lindemann, M., Filonenko, A., 2012. Intercountry assessment of the impact of severe premenstrual disorders on work and daily activities. Health Care for Women International 33 (2), 109–124.
1237
Hsiao, M.C., Hsiao, C.C., Liu, C.Y., 2004. Premenstrual symptoms and premenstrual exacerbation in patients with psychiatric disorders. Psychiatry and Clinical Neurosciences 58 (2), 186–190. Kendler, K.S., Gatz, M., Gardner, C.O., Pedersen, N.L., 2006. A Swedish national twin study of lifetime major depression. American Journal of Psychiatry 163 (1), 109–114. Landen, M., Eriksson, E., 2003. How does premenstrual dysphoric disorder relate to depression and anxiety disorders? Depression and Anxiety 17 (3), 122–129. Miller, L.J., Girgis, C., Gupta, R., 2009. Depression and related disorders during the female reproductive cycle. Womens Health 5 (5), 577–587. Miyaoka, Y., Akimoto, Y., Ueda, K., Ujiie, Y., Kametani, M., Uchiide, Y., Kamo, T., 2011. Fulfillment of the premenstrual dysphoric disorder criteria confirmed using a self-rating questionnaire among Japanese women with depressive disorders. Biopsychosocial Medicine 5, 1–8. Pearlstein, T.B., Frank, E., Rivera-Tovar, A., Thoft, J.S., Jacobs, E., Mieczkowski, T.A., 1990. Prevalence of axis I and axis II disorders in women with late luteal phase dysphoric disorder. Journal of Affective Disorders 20 (2), 129–134. Pilver, C.E., Libby, D.J., Hoff, R.A., 2013. Premenstrual dysphoric disorder as a correlate of suicidal ideation, plans, and attempts among a nationally representative sample. Social Psychiatry and Psychiatric Epidemiology 48 (3), 437–446. Soares, C.N., Zitek, B., 2008. Reproductive hormone sensitivity and risk for depression across the female life cycle: a continuum of vulnerability. Journal of Psychiatry and Neuroscience 33 (4), 331–343. Sprock, J., Yoder, C.Y., 1997. Women and depression: an update on the report of the APA task force. Sex Roles 36, 269–303. Steiner, M., Hirschberg, A.L., Bergeron, R., Holland, F., Gee, M.D., Van Erp, E., 2005. Luteal phase dosing with paroxetine controlled release (CR) in the treatment of premenstrual dysphoric disorder. American Journal of Obstetrics and Gynecology 193 (2), 352–360. Steiner, M., Ravindran, A.V., LeMelledo, J.M., Carter, D., Huang, J.O., Anonychuk, A.M., Simpson, S.D., 2008. Luteal phase administration of paroxetine for the treatment of premenstrual dysphoric disorder: a randomized, double-blind, placebocontrolled trial in Canadian women. Journal of Clinical Psychiatry 69 (6), 991–998. Stewart, J.L., Bismark, A.W., Towers, D.N., Coan, J.A., Allen, J.J.B., 2010. Resting frontal EEG asymmetry as an endophenotype for depression risk: sex-specific patterns of frontal brain asymmetry. Journal of Abnormal Psychology 119 (3), 502–512. Treloar, S.A., Heath, A.C., Martin, N.G., 2002. Genetic and environmental influences on premenstrual symptoms in an Australian twin sample. Psychological Medicine 32 (1), 25–38. Wolk, S.I., Weissman, M.M., 1995. Women and depression: an update. Review of Psychiatry 14, 227–259. Yang, M., Gricar, J.A., Maruish, M.E., Hagan, M.A., Kornstein, S.G., Wallenstein, G.V., 2010. Interpreting Premenstrual Symptoms Impact Survey scores using outcomes in health-related quality of life and sexual drive impact. Journal of Reproductive Medicine 55 (1–2), 41–48. Yang, M., Wallenstein, G., Hagan, M., Guo, A., Chang, J., Kornstein, S., 2008. Burden of premenstrual dysphoric disorder on health-related quality of life. Journal of Women's Health 17 (1), 113–121. Yonkers, K.A., Halbreich, U., Freeman, E., Brown, C., Endicott, J., Frank, E., Parry, B., Pearlstein, T., Severino, S., Stout, A., Stone, A., Harrison, W., 1997. Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. A randomized controlled trial. Sertraline Premenstrual Dysphoric Collaborative Study Group 278 (12), 983–988. Journal of American Medical Association 278 (12), 983–988. Yonkers, K.A., Holthausen, G.A., Poschman, K., Howell, H.B., 2006. Symptom-onset treatment for women with premenstrual dysphoric disorder. Journal of Clinical Psychopharmacology 26 (2), 198–202.