There is excellent data to support the use of selective serotonin and serotonin-norepinephrine reuptake inhibitors (SSRIs and SNRIs) for the treatment of premenstrual dysphoric disorder (PMDD); however, many women do not want to take these medications for symptoms that occur once a month.  Other women do not want to deal with the side effects, which include sexual dysfunction.  What else can we offer to treat premenstrual symptoms?

Over the years, multiple studies have explored the use of cognitive-behavioral therapy (CBT) for the treatment of PMDD and premenstrual symptoms (PMS); however, there has been considerable heterogeneity across the various studies and, according to a recent review, “ a dearth of evidence providing statistically significant CBT intervention effects”.

A recent randomized controlled trial exploring the effectiveness of an internet-based version of CBT for PMDD has yielded more positive results.  In this study, 174 women with PMDD were randomized to the treatment group (n = 86) or a waitlist control group (n = 88). Women in the treatment group received an 8-week course of therapist-guided internet-based CBT.  Using prospective symptom diaries, participants were assessed at baseline, after completing treatment (or waiting list), and again at 6 months after the intervention.

The iCBT intervention consisted of 14 different modules which participants completed over 8 consecutive weeks. In addition to written information, participants received email feedback from a clinical psychologist on a weekly basis. Participants in the waitlist group received the treatment after the end of the waiting period (8 weeks).

The iCBT intervention was based on the Praemensis program (Janda et al, 2015) and included psycho-education (information about PMDD and its etiology), cognitive strategies (e.g., identification and modification of dysfunctional cognitions), and strategies to initiate and/or strengthen healthy lifestyle habits (e.g., exercise, balanced diet, relaxation). Each week the participants were assigned one module dealing with cognitive strategies and one module including suggestions for behavioural changes in lifestyle. In addition, participants received weekly support via e-mail. Therapists were trained to provide supportive and encouraging feedback, making suggestions on how to adapt and modify therapeutic exercises according to participants’ life circumstances and advising participants how to handle difficulties.

The iCBT intervention was shown to be highly effective in reducing the functional and psychological impairment, the impact of premenstrual symptoms on everyday life, and the severity of experienced symptoms.  Follow-up assessments demonstrated that the beneficial effects of treatment were stable over the six months after completion of treatment. In women receiving CBT, higher levels of active coping and lower levels of support-seeking coping were associated with greater improvements in terms of symptom severity and interference with everyday life. In addition, lower levels of perceived stress were associated with greater improvement in functional impairment.

While this study indicates that internet-based CBT may be a highly effective intervention in terms of reducing the symptoms and burden of PMDD, this intervention is not yet available to the general public.  Furthermore, it is unclear when and if this type of intervention will be developed for use beyond the research setting, which is, needless to say, extremely frustrating.  We are in a new place in terms of developing effective treatment strategies; we have inadequate mental health resources, yet we are not positioned to provide more widely accessible alternatives, such as iCBT.

“To harness the full potential of the evolving technology, we underscore the need for academic developers of iCBT and crucially their funding bodies to consider how best to keep pace with the tech world whilst retaining scientific credibility and ensure that iCBT outputs from research can be implemented in a timely manner within routine clinical practice. Going forwards, we advocate that those from the psychological field collaborate with experts from other disciplines and industries, such as e-learning and gaming, to maximize the potential for digital mental health innovations such as iCBT and newer technologies (e.g. virtual reality, augmented reality, artificial intelligence, and wearables).”  (Hill C et al, 2018)

Ruta Nonacs, MD PhD

Janda C, Kues JN, Kleinstaeuber M, Weise C. A therapeutic approach to premenstrual syndrome (PMS): modularized treatment program. Verhaltenstherapie. 2015;25(4):294–303.

Lustyk MK, Gerrish WG, Shaver S, Keys SL.  Cognitive-behavioral therapy for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review. Arch Womens Ment Health. 2009 Apr;12(2):85-96.

Weise C, Kaiser G, Janda C, Kues JN, Andersson G, Strahler J, Kleinstäuber M.  Internet-Based Cognitive-Behavioural Intervention for Women with Premenstrual Dysphoric Disorder: A Randomized Controlled Trial.  Psychother Psychosom. 2019;88(1):16-29.

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