- Email: [email protected]
Lifetime prevalence of psychiatric disorders in women with perimenstrual difficulties
Journal of Affective Elsevier
15
Disorders, 10 (1986) 15-19
JAD 00347
Lifetime Prevalence of Psychiatric Disorders Perimenstrual Difficulties
’ Departments
in Women with
Thomas B. Mackenzie ’ *, Kimerly Wilcox 2 and Howard Baron ’ ofPsychiatryand Medicine and 2 Department of Psychology, University of Minnesota, Minneapolis, MN
55455 (U.S.A.)
(Received 15 August, 1985) (Accepted 10 October, 1985)
Summary Fifty-eight women age 30-40 years, blind to the purpose of the study were segregated according to whether they reported none-mild or moderate-severe perimenstrual difficulties on screening interview. Lifetime prevalence of major psychiatric disorders was ascertained using the Diagnostic Interview Schedule. Women in the moderate-severe group (n = 29) showed a significantly greater lifetime prevalence of affective disorders and drug abuse. No cases of somatization disorder were detected in either group.
Key words:
Diagnostic Interview Schedule Psychiatric disorders
- Drug abuse - Lifetime prevalence
Introduction Menstrually entrained disturbances in psychological and somatic function are widely reported by women during their reproductive years. Among 179 women 18-35 years old recruited from census listings, 30% reported perimenstrual symptoms (Woods et al. 1982). The psychiatric implications of such self-descriptions have attracted considerable interest (Smith 1975). An increased prevalence of psychiatric ill-health in women with premenstrual symptoms compared to control subjects
* Address for correspondence: Thomas B. Mackenzie, M.D., Associate Professor of Psychiatry and Medicine, University of Minnesota, Box 393 Mayo, 420 Delaware St. SE., Minneapolis, MN 55455, U.S.A.
0165-0327/86/$03.50
0 1986 Elsevier Science Publishers
- Perimenstrual
difficulties -
without such symptoms has been demonstrated (Clare 1983). Fewer studies have explored the relationship of premenstrual symptoms to criteria based psychiatric diagnosis and where this has been undertaken, premenstrual phenomena have been generally treated as a dependent variable (Endicott et al. 1981). Thus, the prevalence of specific psychiatric conditions in women with premenstrual difficulties compared to controls selected in the same manner has not been well delineated. Studies treating premenstrual difficulties as an independent variable have found an increased prevalence of affective disorders and an increased incidence of depression in subjects describing premenstrual symptoms compared to controls (Schuckit et al. 1975; Wetzel et al. 1975). However, these studies did not disguise the premenstrual focus of the research and were restricted to sub-
B.V. (Biomedical
Division)
jects below the peak age of risk for affective disorders and premenstrual syndromes. The present study was undertaken to determine the lifetime prevalence of psychiatric disorders in 30-40 year old women who experience perimenstrual difficulties compared to age-matched controls. Perimenstrual difficulties was chosen as an independent variable rather than premenstrual difficulties in order to avoid response biases known to be associated with premenstrual research (see discussion). The research project was approved by the Committee on the Use of Human Subjects in Research at the University of Minnesota. Methods In the spring and summer of 1984, 175 women responded to newspaper advertisements seeking women between 30.-40 years old to participate in a study of “daily changes in health and behavior”. One-hundred and forty-eight of these women were reached by telephone and those who expressed interest (n = 127) completed a telephone screening interview at that time. The interviewer sought demographic information and asked fourteen medical questions, including “are you pregnant or nursing?“, “what medications are you taking?” and “do you now have or have you ever had premenstrual or menstrual difficulties?” If the latter was answered affirmatively, the subject was asked whether her difficulties were mild. moderate or severe. The project was at no time presented to the subjects as a study of the premenstruum and menses. The perimenstrual question was the fifth of nine identically phrased questions about the occurrence of diabetes, high blood pressure, altuberculosis, heart conditions, tumors, lergies, thyroid problems. and headaches. Potential subjects who were pregnant, hysterectomized, nursing or taking oral contraceptives were excluded (n = 22). Unknown to potential subjects, invitations to participate were issued in order to balance membership between two groups: none-mild and moderate-severe premenstrual or menstrual difficulties. All women who described moderate to severe difficulties (n = 32) were invited to participate. Thirty-six of 73 women who rated themselves none or mild were selected according to the chronological priority of their response. Three of the mod-
erate-severe responders and 7 of the none-mild group dropped out prior to meeting with the investigators. Thus, each group was composed of 29 participants, all of whom were Caucasian. Subjects were interviewed at the University of Minnesota Hospitals using the Diagnostic Interview Schedule (DIS), a 265-item structured interview designed to make selected lifetime DSM-III diagnoses (Robins et al. 1981). The interviews were administered by 2 persons trained in administration of the DIS. Each subject was given a $15.00 stipend after completion of the DIS. Following completion of the DIS, subjects were invited to complete a daily self-rating paradigm which lasted 7 weeks. The details of that phase of the study will be reported elsewhere. At the end of the self-rating period, 47 (81%) of the original subjects completed a follow-up interview at which time the Premenstrual Assessment Form (PAF), developed by Halbreich et al. (1982) was administered. The PAF asks the subject to rate the degree of change they experienced relative to 95 items during the previous 3 premenstrual periods. Since the PAF does not disguise its premenstrual focus, subject responses could not be used as an independent variable in the present study. However, because the PAF comprehensively assesses premenstrual symptoms, it was utilized to confirm the validity of the subjects original self-description. Subjects rating themselves as having moderatesevere perimenstrual difficulties were compared with the none-mild participants with respect to the number of items on which premenstrual change was rated moderate, severe or extreme. The distribution of psychiatric diagnoses between the two groups was analyzed using the Fisher Exact Probability Test. Differences between the two groups with respect to number of items rated moderate, severe or extreme on the PAF were compared using a two-tailed t-test. Statistical significance was considered P 5 0.05. Results The subjects in the none-mild and moderatesevere groups were similar with respect to mean age (34.9 vs 34.9), mean number of children (1.79 vs 1.41) percentage married (62% vs 58%), percentage employed out of the home (62% vs 72%)
17
and mean years of education (15.1 vs 14.4). The none-mild subjects (n = 22) completing the PAF rated a mean of 13.3 (SD = 17.9) symptoms as moderate, severe or extreme (range O-57, median 5). Among the moderate-severe subjects completing the PAF (n = 25) the mean was 27.0 (SD = 20.2) (range O-67, median 16). The difference between the two groups was significant at P = 0.02. The prevalence of affective disorders (major depression, bipolar disorder and dysthymia without major depression or bipolar disorder) was significantly greater in the moderate-severe group (Table 1). The prevalence of drug abuse was also significantly greater in the moderate-severe group (Table 1). The patterns of abuse included 2 users of cannabis, 2 of amphetamine and 2 mixed (barbiturate/sedative hypnotic and amphetamine). There was no difference in the prevalence of anxiety disorders or alcohol abuse and no
TABLE
1
COMPARISON OF LIFETIME PREVALENCE DIAGNOSES IN STUDY GROUPS
Disorder
Non-mild Moderate-severe group (n = 29) group (n = 29) n
Affective disorder (major depression, bipolar or dysthymia) Affective disorder (major depression or bipolar) a Drug abuse ’ Alcohol abuse Anxiety disorders Schizophrenia Somatization disorder Antisocial personality disorder Psychosexual dysfunction Any mental disorder (excluding tobacco use disorder and psychosexual dysfunction)
OF DSM-III
6
(W
n
(%)
(21%)
13
(45%) *
(17%)
12
(41%) *
(0%)
(21%) * (14%)
(10%) (21%)
(28%) (0%) (0%) (0%)
(0%) (0%) (0%)
13
* P 5 0.05. ’ Prevalence in ECA samples 7% (Robins et al. 1984). ’ Prevalence in ECA samples 4.4% (Robins et al. 1984).
(17%) (45%)
5 19
(17%) (66%)
among
women
of all ages was
among
women
of all ages was
somatoform, schizophrenic, antisocial personality or organic mental disorders were detected in either group. The difference in the prevalence of any mental disorder in the two groups did not achieve statistical significance. The DIS Version (III) used did not contain supplements for the diagnosis of bulimia or generalized anxiety disorder. Since most subjects (n = 52) described in this study went on to complete daily ratings we were able to estimate on what day they completed the DIS. There was no difference in distribution between the two groups with respect to the interval between completing the DIS and their subsequent menses. Discussion
The study design involved two assumptions: first, that the use of the term “premenstrual” might introduce a bias into the subjects’ self-ratings; and second, that there would be a significant association between a self-report of “premenstrual and menstrual difficulties” and serious premenstrual symptoms. The possibility that the term “premenstrual” creates a response bias has been recently demonstrated by AuBuchon and Calhoun (1985). These authors showed that women informed that they were participants in a premenstrual study responded differently on self-report items assessing mood than women unaware of the study’s focus. The realization that one is participating in a study of psychopathology in women with various levels of premenstrual difficulty might create similar effects. For instance, a woman who is convinced she suffers from a premenstrual syndrome (and not a mental disorder) might deny certain symptoms catalogued by the DIS so as to reduce the likelihood of being assigned a psychiatric diagnosis. Hence, the independent variable (none-mild versus moderate-severe) was assayed as unobtrusively as possible and the respondents were blind to its significance. Even inquiry about the premenstruum was abandoned in favor of a more wide-reachin: question concerning premenstrual or menstrual difficulties since standing alone the term “premenstrual” may be heard by some as a code for emotional instability. The assumption that there would be a signifi-
18
cant association between perimenstrual difficulties and premenstrual symptoms was tested by analyzing the responses of subjects who completed the PAF. The significant association found between the original designation (moderate-severe vs nonemild) and the number of serious premenstrual complaints supports this assumption and indicates that premenstrual symptoms were a major determinant in how subjects responded to our screening inquiry about perimenstrual difficulties. A PAF score of 11 symptoms or more rated moderate, severe or extreme correctly identified 72% of women who reported moderate-severe “perimenstrual difficulties” (sensitivity). Sixty-eight percent of women with none-mild perimenstrual difficulties were correctly classified using this same threshold (specificity). The association of perimenstrual difficulties with affective disorders found in this study is consistent with controlled studies of college populations. Among college freshmen reporting premenstrual symptoms of depression, irritability, anxiety, crying spells and mood changes the lifetime prevalence of depression was 11% compared to 5% for controls (Schuckit et al. 1975). In a similar study 18% of college freshmen endorsing symptoms indicative of a premenstrual affective syndrome sought care for depression during their college years, compared to 10% of controls (Wetzel et al. 1975). The prevalence of affective disorders found in these studies is below that observed in our subjects. This probably reflects the fact that college-aged populations have not entered the period of peak risk for affective disorders. However, the 2-fold increased risk of affective disorders observed in both studies closely resembles the risk found in our population (45% .vs 21%), suggesting that the relative risk associated with perimenstrual difficulties is approximately two and may remain constant throughout the reproductive years. The association of perimenstrual difficulties and drug abuse was unexpected. While some research has pointed to a relationship between alcohol abuse and the premenstruum (Vourakis 1983) evidence of a link between drug abuse and a self-report of perimenstrual difficulties appears to be only anecdotal (Wentz and Jones 1976). If further work confirms this relationship, the possibility that attempts at self-medication during the pre-
menstruum lead to a pattern of abuse will merit consideration. In this regard, evidence that drugs have different reinforcing or physiological properties during the perimenstruum would have important implications. Efforts to demonstrate this have had little success. For instance, Lex et al. (1984) found no significant differences in pulse, subjective intoxication, or confusion following marijuana smoking as a function of menstrual cycle phase. Subjects in the present study were recruited through newspaper advertisements. Those women who answered the advertisement and agreed to participate for a modest stipend may not have constituted a representative sample of women in the 30-40 year-old age range. To check this we compared the lifetime prevalence of any psychiatric disorder in our sample with the prevalence rate found in the NIMH Epidemiologic Catchment Area Program (Robins et al. 1984). Using the DIS (as did the present study), the NIMH study found a 40% lifetime prevalence of any psychiatric disorder in a representative sample of 25544-year-old men and women. The prevalence in our exclusively female population was 55%. However, in order to balance group membership, 90% of women designated moderate or severe entered the study, whereas only 40% of women designated none or mild entered the study. Using this ratio of roughly two to one the prevalence of any psychiatric disorder in women responding to the advertisement study was probably closer to 50%. While this figure is still higher than the 40% found in the NIMH study, it suggests that the study population was not grossly unrepresentative. Efforts to replicate the findings of this study should use random sampling techniques such as those employed in the NIMH project. The increased lifetime prevalence of depressive disorders in women who experience perimenstrual difficulties constitutes the major finding of this study. It extends our understanding of the relationship between the female reproductive cycle and the affective disorders. Not only do women selected for depression have an increased incidence of premenstrual syndromes (Endicott et al. 1981) but women selected for perimenstrual difficulties appear to have an increased prevalence of depression as well. Why should disturbances in the
19
perimenstruum be associated with depression? First, women with perimenstrual difficulties may report more symptoms of any type than controls. Such a tendency was not observed in our sample. While members of the moderate-severe group were twice as likely to report allergies and headaches (both typical premenstrual complaints) on the screening interview, there was no difference in the frequency with which they reported diabetes, hypertension, heart problems, thyroid conditions, tumors, major surgery or other medical conditions. Thus the association is not easily explained as a general response pattern. The possibility remains that perimenstrual difficulties are associated with a particular tendency to over-report depressive symptoms. Why this might be the case is not clear and we know of no evidence of such a phenomena. A second possibility is that episodic disturbances in neuroendocrine function which contribute to perimenstrual difficulties increase the vulnerability to depressive disorders as well. This is not to say that depression and premenstrual phenomena share the same pathophysiological basis, a hypothesis that enjoys little support (Haskett et al. 1980) but that they may share a common set of factors which increases the vulnerability to both. In other words the same endocrine changes which are associated with irritability in the premenstruum, may also favor neurobiological states which increase the liability to depression. Were this the case, different thresholds for each phenomena might exist and it is possible that perimenstrual difficulties identify a group at increased risk for subsequent emergence of depression. While the cross-sectional design of this study prevented testing this hypothesis, it is one that deserves research attention. References AuBuchon, P.G. and Calhoun, K.S., Menstrual tomatology - The role of social expectancy
cycle sympand experi-
mental demand characteristics, Psychosom. Med., 47 (1985) 35-45. Clare, A.W., Psychiatric and social aspects of premenstrual complaint, Psychol. Med., Monograph Supplement 4, 1983. Endicott, J., Halbreich, U., Schacht, S. and Nee, J., Premenstrual changes and affective disorders, Psychosom. Med., 43 (1981) 519-529. Halbreich, U., Endicott, J. and Nee, J., The diversity of premenstrual changes as reflected in the Premenstrual Assessment Form, Acta Psychiat. &and., 65 (1982) 46-65. Haskett, J.F., Steiner, M., Osmun, J.N. and Caroll, B.J., Severe premenstrual tension - Delineation of the syndrome, Biol. Psychiat., 15 (1980) 121-139. Lex, B.W., Mendelson, J.H., Bavli, S., Harvey, K. and Mello, N.K., Effects of acute marijuana smoking on pulse and mood states in women, Psychopharmacology (Berlin), 84 (1984) 178-187. Robins, L.N., Helzer, J.E., Croughan, J., Williams, J.B.W. and Spitzer, R.L., NIMH Diagnostic Interview Schedule, Version III, Washington University School of Medicine, Washington, DC, 1981. Robins, L.N., Helzer, J.E., Weissman, M.M., Orvaschel, E., Gruenberg, E., Burke, J.D. and Regier, D.A., Lifetime prevalence of specific disorders in three sites, Arch. Gen. Psychiat., 41 (1984) 949-958. Schuckit, M.A., Daly, V., Herrman, G. and Hineman, S., Premenstrual symptoms and depression in a university population, Dis. Nerv. Syst., 36 (1975) 516-517. Smith, S.L., Mood and the menstrual cycle. In: E.J. Sachar (Ed.), Topics in Psychoendocrinology, Grune and Stratton, New York, 1975, pp. 18-58. Vourakis, C., Women in substance abuse treatment. In: G. Bennet, C. Vourakis and D.S. Woolf (Eds.), Substance Abuse - Pharmacologic, Developmental and Clinical Perspectives, John Wiley and Sons, New York, 1983, pp. 383-399. Wentz, A.C. and Jones, G.S., Office gynecology - Managing dysmenorrhea, Postgrad. Med., 60 (1976) 161-164. Wetzel, R.D., Reich, T., McClure, J.N. and Wald, J.A., Premenstrual affective syndrome and affective disorder, Brit. J. Psychiat., 127 (1975) 219-221. Woods, N.F., Most, A. and Dery, G.K., Prevalence of perimenstrual symptoms, Amer. J. Public Health, 72 (1982) 1257-1264.
15
Disorders, 10 (1986) 15-19
JAD 00347
Lifetime Prevalence of Psychiatric Disorders Perimenstrual Difficulties
’ Departments
in Women with
Thomas B. Mackenzie ’ *, Kimerly Wilcox 2 and Howard Baron ’ ofPsychiatryand Medicine and 2 Department of Psychology, University of Minnesota, Minneapolis, MN
55455 (U.S.A.)
(Received 15 August, 1985) (Accepted 10 October, 1985)
Summary Fifty-eight women age 30-40 years, blind to the purpose of the study were segregated according to whether they reported none-mild or moderate-severe perimenstrual difficulties on screening interview. Lifetime prevalence of major psychiatric disorders was ascertained using the Diagnostic Interview Schedule. Women in the moderate-severe group (n = 29) showed a significantly greater lifetime prevalence of affective disorders and drug abuse. No cases of somatization disorder were detected in either group.
Key words:
Diagnostic Interview Schedule Psychiatric disorders
- Drug abuse - Lifetime prevalence
Introduction Menstrually entrained disturbances in psychological and somatic function are widely reported by women during their reproductive years. Among 179 women 18-35 years old recruited from census listings, 30% reported perimenstrual symptoms (Woods et al. 1982). The psychiatric implications of such self-descriptions have attracted considerable interest (Smith 1975). An increased prevalence of psychiatric ill-health in women with premenstrual symptoms compared to control subjects
* Address for correspondence: Thomas B. Mackenzie, M.D., Associate Professor of Psychiatry and Medicine, University of Minnesota, Box 393 Mayo, 420 Delaware St. SE., Minneapolis, MN 55455, U.S.A.
0165-0327/86/$03.50
0 1986 Elsevier Science Publishers
- Perimenstrual
difficulties -
without such symptoms has been demonstrated (Clare 1983). Fewer studies have explored the relationship of premenstrual symptoms to criteria based psychiatric diagnosis and where this has been undertaken, premenstrual phenomena have been generally treated as a dependent variable (Endicott et al. 1981). Thus, the prevalence of specific psychiatric conditions in women with premenstrual difficulties compared to controls selected in the same manner has not been well delineated. Studies treating premenstrual difficulties as an independent variable have found an increased prevalence of affective disorders and an increased incidence of depression in subjects describing premenstrual symptoms compared to controls (Schuckit et al. 1975; Wetzel et al. 1975). However, these studies did not disguise the premenstrual focus of the research and were restricted to sub-
B.V. (Biomedical
Division)
jects below the peak age of risk for affective disorders and premenstrual syndromes. The present study was undertaken to determine the lifetime prevalence of psychiatric disorders in 30-40 year old women who experience perimenstrual difficulties compared to age-matched controls. Perimenstrual difficulties was chosen as an independent variable rather than premenstrual difficulties in order to avoid response biases known to be associated with premenstrual research (see discussion). The research project was approved by the Committee on the Use of Human Subjects in Research at the University of Minnesota. Methods In the spring and summer of 1984, 175 women responded to newspaper advertisements seeking women between 30.-40 years old to participate in a study of “daily changes in health and behavior”. One-hundred and forty-eight of these women were reached by telephone and those who expressed interest (n = 127) completed a telephone screening interview at that time. The interviewer sought demographic information and asked fourteen medical questions, including “are you pregnant or nursing?“, “what medications are you taking?” and “do you now have or have you ever had premenstrual or menstrual difficulties?” If the latter was answered affirmatively, the subject was asked whether her difficulties were mild. moderate or severe. The project was at no time presented to the subjects as a study of the premenstruum and menses. The perimenstrual question was the fifth of nine identically phrased questions about the occurrence of diabetes, high blood pressure, altuberculosis, heart conditions, tumors, lergies, thyroid problems. and headaches. Potential subjects who were pregnant, hysterectomized, nursing or taking oral contraceptives were excluded (n = 22). Unknown to potential subjects, invitations to participate were issued in order to balance membership between two groups: none-mild and moderate-severe premenstrual or menstrual difficulties. All women who described moderate to severe difficulties (n = 32) were invited to participate. Thirty-six of 73 women who rated themselves none or mild were selected according to the chronological priority of their response. Three of the mod-
erate-severe responders and 7 of the none-mild group dropped out prior to meeting with the investigators. Thus, each group was composed of 29 participants, all of whom were Caucasian. Subjects were interviewed at the University of Minnesota Hospitals using the Diagnostic Interview Schedule (DIS), a 265-item structured interview designed to make selected lifetime DSM-III diagnoses (Robins et al. 1981). The interviews were administered by 2 persons trained in administration of the DIS. Each subject was given a $15.00 stipend after completion of the DIS. Following completion of the DIS, subjects were invited to complete a daily self-rating paradigm which lasted 7 weeks. The details of that phase of the study will be reported elsewhere. At the end of the self-rating period, 47 (81%) of the original subjects completed a follow-up interview at which time the Premenstrual Assessment Form (PAF), developed by Halbreich et al. (1982) was administered. The PAF asks the subject to rate the degree of change they experienced relative to 95 items during the previous 3 premenstrual periods. Since the PAF does not disguise its premenstrual focus, subject responses could not be used as an independent variable in the present study. However, because the PAF comprehensively assesses premenstrual symptoms, it was utilized to confirm the validity of the subjects original self-description. Subjects rating themselves as having moderatesevere perimenstrual difficulties were compared with the none-mild participants with respect to the number of items on which premenstrual change was rated moderate, severe or extreme. The distribution of psychiatric diagnoses between the two groups was analyzed using the Fisher Exact Probability Test. Differences between the two groups with respect to number of items rated moderate, severe or extreme on the PAF were compared using a two-tailed t-test. Statistical significance was considered P 5 0.05. Results The subjects in the none-mild and moderatesevere groups were similar with respect to mean age (34.9 vs 34.9), mean number of children (1.79 vs 1.41) percentage married (62% vs 58%), percentage employed out of the home (62% vs 72%)
17
and mean years of education (15.1 vs 14.4). The none-mild subjects (n = 22) completing the PAF rated a mean of 13.3 (SD = 17.9) symptoms as moderate, severe or extreme (range O-57, median 5). Among the moderate-severe subjects completing the PAF (n = 25) the mean was 27.0 (SD = 20.2) (range O-67, median 16). The difference between the two groups was significant at P = 0.02. The prevalence of affective disorders (major depression, bipolar disorder and dysthymia without major depression or bipolar disorder) was significantly greater in the moderate-severe group (Table 1). The prevalence of drug abuse was also significantly greater in the moderate-severe group (Table 1). The patterns of abuse included 2 users of cannabis, 2 of amphetamine and 2 mixed (barbiturate/sedative hypnotic and amphetamine). There was no difference in the prevalence of anxiety disorders or alcohol abuse and no
TABLE
1
COMPARISON OF LIFETIME PREVALENCE DIAGNOSES IN STUDY GROUPS
Disorder
Non-mild Moderate-severe group (n = 29) group (n = 29) n
Affective disorder (major depression, bipolar or dysthymia) Affective disorder (major depression or bipolar) a Drug abuse ’ Alcohol abuse Anxiety disorders Schizophrenia Somatization disorder Antisocial personality disorder Psychosexual dysfunction Any mental disorder (excluding tobacco use disorder and psychosexual dysfunction)
OF DSM-III
6
(W
n
(%)
(21%)
13
(45%) *
(17%)
12
(41%) *
(0%)
(21%) * (14%)
(10%) (21%)
(28%) (0%) (0%) (0%)
(0%) (0%) (0%)
13
* P 5 0.05. ’ Prevalence in ECA samples 7% (Robins et al. 1984). ’ Prevalence in ECA samples 4.4% (Robins et al. 1984).
(17%) (45%)
5 19
(17%) (66%)
among
women
of all ages was
among
women
of all ages was
somatoform, schizophrenic, antisocial personality or organic mental disorders were detected in either group. The difference in the prevalence of any mental disorder in the two groups did not achieve statistical significance. The DIS Version (III) used did not contain supplements for the diagnosis of bulimia or generalized anxiety disorder. Since most subjects (n = 52) described in this study went on to complete daily ratings we were able to estimate on what day they completed the DIS. There was no difference in distribution between the two groups with respect to the interval between completing the DIS and their subsequent menses. Discussion
The study design involved two assumptions: first, that the use of the term “premenstrual” might introduce a bias into the subjects’ self-ratings; and second, that there would be a significant association between a self-report of “premenstrual and menstrual difficulties” and serious premenstrual symptoms. The possibility that the term “premenstrual” creates a response bias has been recently demonstrated by AuBuchon and Calhoun (1985). These authors showed that women informed that they were participants in a premenstrual study responded differently on self-report items assessing mood than women unaware of the study’s focus. The realization that one is participating in a study of psychopathology in women with various levels of premenstrual difficulty might create similar effects. For instance, a woman who is convinced she suffers from a premenstrual syndrome (and not a mental disorder) might deny certain symptoms catalogued by the DIS so as to reduce the likelihood of being assigned a psychiatric diagnosis. Hence, the independent variable (none-mild versus moderate-severe) was assayed as unobtrusively as possible and the respondents were blind to its significance. Even inquiry about the premenstruum was abandoned in favor of a more wide-reachin: question concerning premenstrual or menstrual difficulties since standing alone the term “premenstrual” may be heard by some as a code for emotional instability. The assumption that there would be a signifi-
18
cant association between perimenstrual difficulties and premenstrual symptoms was tested by analyzing the responses of subjects who completed the PAF. The significant association found between the original designation (moderate-severe vs nonemild) and the number of serious premenstrual complaints supports this assumption and indicates that premenstrual symptoms were a major determinant in how subjects responded to our screening inquiry about perimenstrual difficulties. A PAF score of 11 symptoms or more rated moderate, severe or extreme correctly identified 72% of women who reported moderate-severe “perimenstrual difficulties” (sensitivity). Sixty-eight percent of women with none-mild perimenstrual difficulties were correctly classified using this same threshold (specificity). The association of perimenstrual difficulties with affective disorders found in this study is consistent with controlled studies of college populations. Among college freshmen reporting premenstrual symptoms of depression, irritability, anxiety, crying spells and mood changes the lifetime prevalence of depression was 11% compared to 5% for controls (Schuckit et al. 1975). In a similar study 18% of college freshmen endorsing symptoms indicative of a premenstrual affective syndrome sought care for depression during their college years, compared to 10% of controls (Wetzel et al. 1975). The prevalence of affective disorders found in these studies is below that observed in our subjects. This probably reflects the fact that college-aged populations have not entered the period of peak risk for affective disorders. However, the 2-fold increased risk of affective disorders observed in both studies closely resembles the risk found in our population (45% .vs 21%), suggesting that the relative risk associated with perimenstrual difficulties is approximately two and may remain constant throughout the reproductive years. The association of perimenstrual difficulties and drug abuse was unexpected. While some research has pointed to a relationship between alcohol abuse and the premenstruum (Vourakis 1983) evidence of a link between drug abuse and a self-report of perimenstrual difficulties appears to be only anecdotal (Wentz and Jones 1976). If further work confirms this relationship, the possibility that attempts at self-medication during the pre-
menstruum lead to a pattern of abuse will merit consideration. In this regard, evidence that drugs have different reinforcing or physiological properties during the perimenstruum would have important implications. Efforts to demonstrate this have had little success. For instance, Lex et al. (1984) found no significant differences in pulse, subjective intoxication, or confusion following marijuana smoking as a function of menstrual cycle phase. Subjects in the present study were recruited through newspaper advertisements. Those women who answered the advertisement and agreed to participate for a modest stipend may not have constituted a representative sample of women in the 30-40 year-old age range. To check this we compared the lifetime prevalence of any psychiatric disorder in our sample with the prevalence rate found in the NIMH Epidemiologic Catchment Area Program (Robins et al. 1984). Using the DIS (as did the present study), the NIMH study found a 40% lifetime prevalence of any psychiatric disorder in a representative sample of 25544-year-old men and women. The prevalence in our exclusively female population was 55%. However, in order to balance group membership, 90% of women designated moderate or severe entered the study, whereas only 40% of women designated none or mild entered the study. Using this ratio of roughly two to one the prevalence of any psychiatric disorder in women responding to the advertisement study was probably closer to 50%. While this figure is still higher than the 40% found in the NIMH study, it suggests that the study population was not grossly unrepresentative. Efforts to replicate the findings of this study should use random sampling techniques such as those employed in the NIMH project. The increased lifetime prevalence of depressive disorders in women who experience perimenstrual difficulties constitutes the major finding of this study. It extends our understanding of the relationship between the female reproductive cycle and the affective disorders. Not only do women selected for depression have an increased incidence of premenstrual syndromes (Endicott et al. 1981) but women selected for perimenstrual difficulties appear to have an increased prevalence of depression as well. Why should disturbances in the
19
perimenstruum be associated with depression? First, women with perimenstrual difficulties may report more symptoms of any type than controls. Such a tendency was not observed in our sample. While members of the moderate-severe group were twice as likely to report allergies and headaches (both typical premenstrual complaints) on the screening interview, there was no difference in the frequency with which they reported diabetes, hypertension, heart problems, thyroid conditions, tumors, major surgery or other medical conditions. Thus the association is not easily explained as a general response pattern. The possibility remains that perimenstrual difficulties are associated with a particular tendency to over-report depressive symptoms. Why this might be the case is not clear and we know of no evidence of such a phenomena. A second possibility is that episodic disturbances in neuroendocrine function which contribute to perimenstrual difficulties increase the vulnerability to depressive disorders as well. This is not to say that depression and premenstrual phenomena share the same pathophysiological basis, a hypothesis that enjoys little support (Haskett et al. 1980) but that they may share a common set of factors which increases the vulnerability to both. In other words the same endocrine changes which are associated with irritability in the premenstruum, may also favor neurobiological states which increase the liability to depression. Were this the case, different thresholds for each phenomena might exist and it is possible that perimenstrual difficulties identify a group at increased risk for subsequent emergence of depression. While the cross-sectional design of this study prevented testing this hypothesis, it is one that deserves research attention. References AuBuchon, P.G. and Calhoun, K.S., Menstrual tomatology - The role of social expectancy
cycle sympand experi-
mental demand characteristics, Psychosom. Med., 47 (1985) 35-45. Clare, A.W., Psychiatric and social aspects of premenstrual complaint, Psychol. Med., Monograph Supplement 4, 1983. Endicott, J., Halbreich, U., Schacht, S. and Nee, J., Premenstrual changes and affective disorders, Psychosom. Med., 43 (1981) 519-529. Halbreich, U., Endicott, J. and Nee, J., The diversity of premenstrual changes as reflected in the Premenstrual Assessment Form, Acta Psychiat. &and., 65 (1982) 46-65. Haskett, J.F., Steiner, M., Osmun, J.N. and Caroll, B.J., Severe premenstrual tension - Delineation of the syndrome, Biol. Psychiat., 15 (1980) 121-139. Lex, B.W., Mendelson, J.H., Bavli, S., Harvey, K. and Mello, N.K., Effects of acute marijuana smoking on pulse and mood states in women, Psychopharmacology (Berlin), 84 (1984) 178-187. Robins, L.N., Helzer, J.E., Croughan, J., Williams, J.B.W. and Spitzer, R.L., NIMH Diagnostic Interview Schedule, Version III, Washington University School of Medicine, Washington, DC, 1981. Robins, L.N., Helzer, J.E., Weissman, M.M., Orvaschel, E., Gruenberg, E., Burke, J.D. and Regier, D.A., Lifetime prevalence of specific disorders in three sites, Arch. Gen. Psychiat., 41 (1984) 949-958. Schuckit, M.A., Daly, V., Herrman, G. and Hineman, S., Premenstrual symptoms and depression in a university population, Dis. Nerv. Syst., 36 (1975) 516-517. Smith, S.L., Mood and the menstrual cycle. In: E.J. Sachar (Ed.), Topics in Psychoendocrinology, Grune and Stratton, New York, 1975, pp. 18-58. Vourakis, C., Women in substance abuse treatment. In: G. Bennet, C. Vourakis and D.S. Woolf (Eds.), Substance Abuse - Pharmacologic, Developmental and Clinical Perspectives, John Wiley and Sons, New York, 1983, pp. 383-399. Wentz, A.C. and Jones, G.S., Office gynecology - Managing dysmenorrhea, Postgrad. Med., 60 (1976) 161-164. Wetzel, R.D., Reich, T., McClure, J.N. and Wald, J.A., Premenstrual affective syndrome and affective disorder, Brit. J. Psychiat., 127 (1975) 219-221. Woods, N.F., Most, A. and Dery, G.K., Prevalence of perimenstrual symptoms, Amer. J. Public Health, 72 (1982) 1257-1264.