PMS & PMDD

In community-based and clinical studies, it has been observed that about 60% of women with mood disorders experience worsening of their mood during the premenstrual phase of their cycle.  While this is often referred to as premenstrual dysphoric disorder or PMDD, it is more accurate -- and clinically important -- to recognize this as premenstrual  exacerbation of a mood disorder or PME. In contrast to PMDD, PME is understudied.   A recent review from Kuehner and Nayman (full text available HERE) discusses the diagnosis of PME, as well as the epidemiology, underlying mechanisms, and treatment of PME in women with unipolar depression and bipolar disorder. Kuehner C, Nayman S. Premenstrual Exacerbations of Mood Disorders: Findings and Knowledge Gaps. Curr Psychiatry ...
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Neuroactive steroids or neurosteroids are a new class of medications which appear to have anxiolytic and antidepressant effects and have received a great deal of attention over the past few years.  Most of neuroactive steroids currently under investigation as antidepressants are derivatives of allopregnanolone.  In the human body, the hormone progesterone is metabolized into a variety of active and inactive compounds, including allopregnanolone.  It is hypothesized that these allopregnanolone derivatives ameliorate anxiety and depressive symptoms by modulating the hypothalamic-pituitary-adrenal or HPA axis which mediates the body’s response to stress and is modulated by GABAergic signaling. The first neurosteroid to generate a great deal of excitement was brexanolone which was approved by the FDA for the treatment of postpartum depression.  Zuranolone, ...
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In an evidence-based review published in 2012, Laura Wakil, Samantha Meltzer-Brody, and Susan Girdler present a thorough review of premenstrual dysphoric disorder (PMDD), reviewing its diagnosis and treatment options.  The information provided is clear and provides an excellent framework for understanding PMDD.  In addition, this article includes a section on the association between PMS/PMDD and a history of sexual or physical trauma, an important topic that other reviews have typically not included. Although published 9 years ago, there are not many reviews on PMDD out there, and this is a good one.  With regard to treatment and diagnosis, little has changed over the last decade.  PMDD is now classified as a mental illness in the Diagnostic and Statistical Manual of ...
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While many women experience physical symptoms prior to the onset of their period or premenstrual syndrome (PMS), a smaller subset of women suffer from Premenstrual Dysphoric Disorder (PMDD), a more severe form of premenstrual syndrome.  PMDD is characterized by significant premenstrual mood disturbance, often with prominent mood reactivity, irritability, and depression. Symptoms of PMDD can emerge 1-2 weeks preceding menses and typically resolve with the onset of menses. This mood disturbance results in marked social or occupational impairment, with its most prominent effects noted in interpersonal functioning.  Serotonergic antidepressants have been established as the first-line treatment option for PMDD; however, some women either do not tolerate or fail to respond to this class of medications.  Some women may benefit from ...
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The following post was first published in Current Psychiatry, published September 2017, Vol. 16, No. 9, p. 20-28. Check out the article on Current Psychiatry or listen to Dr. Raffi discuss treatment of menstrual–related mood and anxiety disorders. By Edwin R. Raffi, MD, MPH, & Marlene P. Freeman, MD In an age when psychiatry strives to identify the biologic causes of disease, studying endocrine-related mood disorders is particularly intriguing. DSM-5 defines premenstrual dysphoric disorder (PMDD) as a depressive disorder, with a 12-month prevalence ranging from 1.8% to 5.8% among women who menstruate.1-3 Factors that differentiate PMDD from other affective disorders include etiology, duration, and temporal relationship with the menstrual cycle. PMDD is a disorder of consistent yet intermittent change in mental health ...
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INFERTILITY & MENTAL HEALTH

This week we are pleased to have a guest post from Dr. Anna Glezer.  She is a perinatal psychiatrist practicing at the University of California San Francisco and the founder of Mind Body Pregnancy, a new online resource uniquely focusing on all topics related to the emotional health of women during their reproductive years. Infertility, affecting many couples, can have a number of mental health complications like depression. The most common treatment medications can themselves also have effects on a woman’s emotional state. Clomiphene (Clomid) and Human Menopausal Gonadotropin One of the most commonly prescribed medications in infertility treatment is clomiphene.  Clomiphene is a medication used to treat ovulation problems, a common reason for infertility. It works by affecting a ...
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PSYCHIATRIC DISORDERS DURING PREGNANCY

The Journal of Clinical Psychiatry recently published a series of articles on the use of valproic acid in women of childbearing age.  We all agree that valproic acid is a teratogen and is associated with unacceptably high rates of major congenital malformations, including neural tube defects, neurodevelopmental disorders, and other adverse outcomes. Where there seems to be a divergence of opinions, however, is whether or not valproic acid should be used at all in women of childbearing age.  Several other countries have put strict limitations on the use of valproic acid in reproductive aged women; the United States has not. Chittaranjan Andrade, MD, et al: Use of Valproate in Women: An Audit of Prescriptions to ...
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Analyzing data from nearly 150,000 children with prenatal antidepressant exposure in two healthcare databases, a recent study finds no association between prenatal exposure to antidepressants and risk for neurodevelopmental disorders.    In a recent commentary, Dr. Lee Cohen, notes that over the last 15-20 years, we have collected an enormous amount of data on the use of antidepressants during pregnancy.  Data from multiple studies and meta-analyses have demonstrated no increased risk of major malformations in children exposed to antidepressants during pregnancy, including the SSRIs, SNRIs, tricyclic antidepressants and bupropion.    “However,” he notes, “for so many clinicians and for patients, the missing piece in the risk-benefit equation has been the issue of long-term neurodevelopmental sequelae in ...
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Neural tube defects (NTDs) are among the most common major malformations in the United States. Daily folic acid supplementation in the periconceptional period significantly reduces the risk of neural tube defects.  However, most women do not receive the recommended daily intake of folate from diet alone; thus, it is recommended that all women of childbearing age should take supplemental folic acid. Since half of all pregnancies in the US are unplanned, the US Preventive Services TAsk Force recommends that all women who are capable of getting pregnant should take a daily supplement or multivitamin containing 0.4 to 0.8 mg (400 to 800 mcg) of folic acid.  In terms of preventing neural tube defects, the critical ...
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While we have a body of literature assessing risk of malformations in children exposed to benzodiazepines during pregnancy, there is considerably less information on the effects of this class of medications on long-term neurodevelopmental outcomes.  A recent systematic review from Wang and colleagues (FULL TEXT) pulls together the limited information we have on neurodevelopmental outcomes in children with in utero exposure to benzodiazepines and sedative-hypnotic drugs (Z-drugs). The review summarizes data drawn from a total of 19 studies, which were conducted between 1958 and 2016 (summarized in Table 1).  The authors note considerable variation with regard to methodologies and types of assessments used.  Importantly, they observe that benzodiazepines and Z-drugs are used to treat a ...
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About 10% to 15% of women experience clinically significant depressive symptoms during pregnancy. Furthermore, women with a history of major depression appear to be at high risk for recurrent illness during pregnancy particularly in the setting of antidepressant discontinuation.  We have long argued that it is important to identify and to offer treatment to women who suffer from depression during pregnancy, but we have yet to agree on what is the best instrument for this purpose. Using the EPDS to Identify Depression During Pregnancy? The Edinburgh Postnatal Depression Scale (EPDS), although initially engineered to detect postpartum depression, has been used in pregnant populations; however, there has been considerable variability in the estimates of the sensitivity ...
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It is not easy to stay on top of the medical literature in any field.  The number of journals and publications has increased dramatically over the last decade.  When we first started this website, there were a handful of articles to read each week.  Now, it is easy to find 50 or so publications each week that are relevant to the practice of perinatal psychiatry.   On our website, we try to stay abreast of the latest news, and you are, of course, welcome to continue to use our website as your primary source of information.  But many people want to know  what I read and how I find out about current literature.  I am including ...
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In this Special Report published in Psychiatric News, Dr. Laura Miller reviews the data regarding the impact of stress experienced by the mother during pregnancy on pregnancy outcomes and fetal development. “I just feel like I am broken. I am the worst pregnant woman ever.” These are the words of a woman interviewed by Aleksandra Staneva, Ph.D., and colleagues as they conducted a study on how women experience and interpret psychological distress while they are pregnant. The study was reported in the June 2017 Health Care for Women International. What they learned is that for many women, experiencing distress during pregnancy runs smack into unrealistic cultural expectations and fuels excessive guilt. Women report feeling totally responsible ...
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It is estimated that up to 95% of women experience some type of sleep disturbance during pregnancy.  While for many women the insomnia is relatively benign and may respond to simple interventions, other women experience more severe insomnia which has a significant impact on their quality of life and ability to function.  Trazodone (Desyrel) is FDA-approved for the treatment of major depressive disorder; however, because it is highly sedating, it is more commonly used to promote sleep.  However, information regarding the reproductive safety of these medications has been relatively sparse. Insomnia, especially when severe, may be associated with worse pregnancy outcomes and may increase risk for depression during pregnancy and the postpartum period.  The treatment ...
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