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 only 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?

A few weeks ago, we reviewed a study using internet-based cognitive-behavioral therapy for the treatment of PMDD.  Although we are seeing many studies supporting the use of mindfulness-based treatments for mood and anxiety disorders, there is much less information on the use of this intervention for women with premenstrual symptoms.  In this article, we review one study, published in 2016, which explored the use of mindfulness-based cognitive therapy (MBCT) for treating women with premenstrual symptoms.  

In this randomized controlled trial, a total of 60 female college students with mild to moderate premenstrual syndrome (PMS) associated with depressive symptoms (Beck Depression Inventory scores 16-47) were randomly assigned to an MBCT group (n=30) or to a control group (n=30).  

Women in the MBCT group received eight group sessions (120?minutes each) over eight weeks. The control group received no intervention. All participants completed the Premenstrual Assessment Scale (PAS), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) at baseline and at the end of the study. 

The MBCT intervention consisted of the following modules:

Session 1: Building a therapeutic alliance, identifying automatic thoughts, and introducing the body scan and  mindfulness meditation with in-session practice.   Assignment: reading about the body scan meditation technique, 30-minute daily formal practice.  

Session 2: Helping the patient recognize that thoughts are not facts, teaching how to use the thought record, sitting meditation using breath as the primary object of awareness, and alternating this with the body scan.  Assignment: reading about and doing formal and informal sitting meditation.

Session 3: Dealing with automatic thoughts in life and in meditation and walking meditation. Assignment: mindful yoga.

Session 4: Stopping one-minute breathing space. Assignment: mindful yoga and sitting meditation (continued throughout trial period).

Session 5: Dealing with difficult emotions, wisdom meditation, and walking meditation. Assignment: mindful yoga.

Session 6: Communication. Assignment: listening to others carefully and mindful yoga.

Session 7: Self-compassion. Assignment: loving yourself and mindful Yoga.

Session 8: Helping the patient develop a practice of her own, reviewing progress, insights, and techniques, and individual evaluation of the sessions.

Women receiving MBCT, compared to those receiving no intervention, experienced statistically significant reductions in depressive symptoms (post-treatment 15.73 ± 6.99 vs. 25.36 ± 7.14), anxiety (16.96 ± 7.78 vs. 26.60 ± 9.38), and total scores on the PAS.  

While this study indicates that MBCT intervention is acceptable to women with premenstrual symptoms and may be helpful for relieving symptoms of depression and anxiety, some questions remain.  It is important to note that the women included in this trial described PMS, which is typically milder than premenstrual dysphoric disorder (PMDD); however, the mean score on the BDI at baseline was 24.70 (range 16-47), which suggests that all women had at least mild depression and many had moderate to severe depression. 

The Premenstrual Assessment Scale or PAS was used to indicate premenstrual symptoms, but this tool is not typically used to confirm the diagnosis of PMDD.  I suspect that, based on the severity of depressive symptoms and anxiety, it is possible that many women in this study have bonafide PMDD, although it is possible that women may have an underlying mood or anxiety disorder which worsens premenstrually.  

Further studies will need to determine if this intervention is effective for PMDD, which may be clinically distinct from other mood and anxiety disorders.  Nonetheless, it is a study which supports the further exploration of another modality for addressing premenstrual symptoms.  While SSRIs and SNRIs may work for many women, a considerable number of women have side effects at higher doses of medication or do not achieve a full response.  If effective for PMDD, MBCT could thus be used as a standalone treatment or to augment traditional pharmacologic treatments. 

Ruta Nonacs, MD PhD

Panahi F, Faramarzi M.   The Effects of Mindfulness-Based Cognitive Therapy on Depression and Anxiety in Women with Premenstrual Syndrome.  Depress Res Treat 2016. Free Article

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