Fluoxetine in the treatment of premenstrual dysphoria. Canadian Fluoxetine/Premenstrual Dysphoria Collaborative Study Group

Premenstrual syndromes

The recent inclusion of research criteria for premenstrual dysphoric disorder in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders should help physicians recognize women with symptoms of irritability, tension, dysphoria, and lability of mood that seriously interfere with their lifestyle. Premenstrual dysphoric disorder can be differentiated from premenstrual syndrome, which is primarily reserved for milder physical symptoms and minor mood changes. The use of criteria from the Diagnostic and Statistical Manual in conjunction with prospective daily charting for at least two menstrual cycles is now accepted as common practice in confirming the diagnosis. Treatment options range from the conservative (lifestyle and stress management) to treatment with psychotropic medications and hormonal or surgical interventions to eliminate ovulation for the more extreme cases. Results from several randomized, placebo-controlled trials have clearly demonstrated that selective serotonin reuptake inhibitors, as well as medical or surgical oophorectomy, are effective in treating premenstrual dysphoric disorder. Taken together, these data indicate that treatment may be accomplished by either eliminating the hormonal trigger or by reversing the sensitivity of the serotonergic system.

Serotonin re-uptake inhibitors in the treatment of premenstrual dysphoria: Current state of knowledge

Late luteal phase dysphoric disorder (LLPDD) and the more recently introduced premenstrual dysphoric disorder (PMDD) are recognized psychiatric disorders that consist of distressing emotional and behavioural symptoms that occur premenstrually. Recently, advances have been made in understanding the aetiology of the disorder, with clear evidence to implicate the serotonergic system. In women with predominately psychological symptoms, selective serotonin re-uptake inhibitors (SSRIs), as well as clomipramine, have demonstrated excellent efficacy and minimal side effects.

Diagnosis and treatment of premenstrual dysphoric disorder

Premenstrual syndrome (PMS) is a common problem and patients with PMS are encountered by obstetricians, gynecologists, family practitioners, internists (general physicians) and psychiatrists. Despite several decades of biological research, the etiology of the disorder is still elusive. The introduction of a psychiatric category called premenstrual dysphoric disorder (PMDD), describing women with severe emotional premenstrual symptoms, has advanced biological treatment research by identifying a more homogeneous patient population. This paper aims to review our current understanding of the clinical presentation, underlying psycho-biology, and essentials of treatment for premenstrual dysphoric disorder.

Serotonin and gender-specific psychiatric disorders

The serotonergic system has been linked to the etiology of several, albeit disparate, psychiatric disorders. The accumulation of many lines of evidence support the view that there are gender differences in the serotonergic system in humans. It is further proposed that a gender differentiated serotonergic system acts as the nidus for the development of gender-specific psychiatric disorders. Depression, anxiety and eating disorders are largely seen in females, whereas alcoholism, aggressivity and suicide predominate in males. Evidence from both animal and human studies suggesting that the serotonergic system mediates between social-environmental experience and biological states is presented and reviewed. A reconceptualization of the serotonergic system as a gender-specific psychobiological interface is proposed. (Int J Psych Clin Prac 1997; 1: 3-13).

Menarche and the onset of depression and anxiety in Victoria, Australia

STUDY OBJECTIVE

Psychiatric disorder often begins at adolescence. This study aimed to examine the associations between puberty and social circumstances and the adolescent rise in depression and anxiety.

DESIGN

A two stage cluster sampling procedure was used to identify a representative group of Australian secondary school students in years 7 (age 12-13 years), 9 (14-15 years), and 11 (16-17 years) of 45 Victorian schools. The computerised clinical interview schedule (CIS) was used to evaluate psychiatric morbidity.

MAIN RESULTS

A total of 2525 subjects completed the survey - an overall participation rate of 83%. Levels of depression and anxiety increased with the secondary school years and girls had significantly higher rates at each school year level. For boys, the clearest independent associations with depression and anxiety were rising school year level and high parental educational achievement. For girls menarchal status emerged as the strongest predictor. Associations with age and school year level, evident on univariate analysis, did not persist when the recency of menarche was taken into account. After addition of measures of perceived social stress to a multivariate model, a significant association between depression/anxiety and parental divorce disappeared but the association with menarche persisted.

CONCLUSIONS

Menarche marks a transition in the risk of depression and anxiety in girls. The pattern of findings is consistent with a biological mediation of this association.

Gender, quality of life, and mental disorders in primary care: results from the PRIME-MD 1000 study

BACKGROUND

Recently there has been increased interest in the special mental health needs of women. We used data from the PRIME-MD 1000 study to assess gender differences in the frequency of mental disorders in primary care settings, and to explore the potential impact of these differences on health-related quality of life (HRQL).

SUBJECTS AND METHODS

One thousand primary care patients (559 women) were interviewed during the PRIME-MD study, which was conducted at four primary care clinics affiliated with university hospitals throughout the eastern United States. Patients completed a one-page questionnaire in the waiting room prior to being seen by the physician; patients and physicians then completed together a clinician evaluation guide that used DSM-III-R algorithms to diagnose mood, anxiety, somatoform, eating, and alcohol related disorders. Health-related quality of life was assessed with the Medical Outcomes Study SF-20 General Health Survey.

RESULTS

Women were more likely than men to have at least one mental disorder (43% versus 33%, P < 0.05). Higher rates were particularly prominent for mood disorders (31% of women versus 19% of men, odds ratio [OR] = 1.9, 95% confidence interval [CI] 1.4 to 2.6), anxiety disorders (22% versus 13%, OR = 1.9, CI = 1.3 to 2.8), and somatoform disorders (18% versus 9%, OR = 2.2, CI = 1.5 to 3.4). Psychiatric comorbidity was also more common in women (26% of women had two or more mental disorders versus 15% of men, P < 0.05). Unadjusted HRQL scores, ranging from 0 to 100, with 100 = best health, were all significantly lower in women than in men (eg, physical function = 67 in women versus 76 in men, P < 0.0001; mental health = 69 in women versus 76 in men, P < 0.0001). Many HRQL differences persisted after controlling for age, education, ethnicity, marital status, and number of physical disorders; however, differences in HRQL were eliminated in 5 of 6 domains after controlling for number of mental disorders. When compared with female patients of male physicians, female patients of female physicians demonstrated similar satisfaction with care, health care utilization, HRQL, and recognition rate of mental disorders.

CONCLUSIONS

In the 1,000 patients of the PRIME-MD study, mood, anxiety, and somatoform disorders and psychiatric comorbidity were all significantly more common in women than men. The HRQL scores were poorer in women than men, although most of this difference was accounted for by the difference in prevalence of mental disorders. These data suggest that one of the most important aspects of a primary care physician's care of female patients is to screen for and treat common mental disorders.

The addition of dexfenfluramine to fluoxetine in the treatment of obesity: a randomized clinical trial

Current evidence demonstrates that pharmacologic agents, alone or in combination produce short-term weight-loss and may remain effective for extended periods of time in obese patients. We have evaluated the weight loss of a selective inhibitor of serotonin uptake, fluoxetine, alone as compared with combined therapeutic trial with another serotoninergic drug, dexfenfluramine. Thirty-three patients were randomly assigned in a double-blind randomized clinical trial divided to two groups: Group I [Fluoxetine 40 mg and placebo (n = 13)] and Group II [Fluoxetine 40 mg plus dexfenfluramine 15 mg at night (n = 20)]. Both groups had a significant weight loss at the end of 8 months (Group I, mean +/- SEM 6.2 +/- 2.8 kg and Group II 13.4 +/- 6.3 kg, p < 0.05). Group II patients had a significantly greater weight loss as compared with Group I both in terms of mean weight loss in kg and BMI in kg/m2. However significance between Group I and II related to BMI mean values and weight mean values were only achieved after, respectively, 4 and 6 months of treatment. At laboratory level there was an elevation of HDL-cholesterol and lowering of serum lipids values (cholesterol and triglycerides) in both groups. Side effects were relatively minor and no altered clinical vital signs or abnormal laboratory values were observed. We concluded that the combination of fluoxetine (daytime) and dexfenfluramine (at night) may be more effective than fluoxetine alone in weight reduction although the small size of this study does not permit broad generalization.

Fluoxetine-elicited changes in brain neurosteroid content measured by negative ion mass fragmentography

Fluoxetine administered intraperitoneally to sham-operated or adrenalectomized/castrated (ADX/CX) male rats dose-dependently (2.9-58 mumol/kg i.p.) increased the brain content of the neurosteroid 3 alpha-hydroxy-5 alpha-pregnan-20-one (allopregnanolone, 3 alpha, 5 alpha-TH PROG). The increase of brain 3 alpha, 5 alpha-TH PROG content elicited by 58 mumol/kg fluoxetine lasted more than 2 hr and the range of its extent was comparable in sham-operated (approximately 3-10 pmol/g) and ADX/CX rats (2-9 pmol/g) and was associated with a decrease (from 2.8 to 1.1 pmol/g) in the 5 alpha-pregnan-3,20-dione (5 alpha-dihydroprogesterone, 5 alpha-DH PROG) content. The pregnenolone, progesterone, and dehydroepiandrosterone content failed to change in rats receiving fluoxetine. The extent of 3 alpha, 5 alpha-TH PROG accumulation elicited by fluoxetine treatment differed in various brain regions, with the highest increase occurring in the olfactory bulb. Importantly, fluoxetine failed to change the 3 alpha, 5 alpha-TH PROG levels in plasma, which in ADX/CX rats were at least two orders of magnitude lower than in the brain. Two other serotonin re-uptake inhibitors, paroxetine and imipramine, in doses equipotent to those of fluoxetine in inhibiting brain serotonin uptake, were either significantly less potent than fluoxetine (paroxetine) or failed to increase (imipramine) 3 alpha, 5 alpha-TH PROG brain content. The addition of 10 microM of 5 alpha-DH PROG to brain slices of ADX/CX rats preincubated with fluoxetine (10 microM, 15 min) elicited an accumulation of 3 alpha, 5 alpha-TH PROG greater than in slices preincubated with vehicle. A fluoxetine stimulation of brain 3 alpha, 5 alpha-TH PROG biosynthesis might be operative in the anxiolytic and antidysphoric actions of this drug.

Individual differences in changes in mood and platelet monoamine oxidase (MAO) activity during hormonal replacement therapy in menopausal women

Estrogen replacement treatment in menopausal women has been reported to have a positive effect on mood states. However, the addition of a progestin partially negates this positive effect in some women. The opposite effects of estrogen and progestin on mood may relate to their opposite effects on adrenergic and serotonergic neural function. In a double-blind, placebo-controlled, crossover study, 38 nondepressed menopausal women were cyclically treated with estrogen and estrogen plus progestin, or with placebo, for five 28-day cycles. This paper identifies the pretreatment attributes of women who do and do not have negative mood responses to progestin, and examines the relationship of these adverse side-effects to platelet monoamine oxidase (MAO), a marker of adrenergic and serotonergic functioning. Adverse mood responses to progestin occur in women with a long duration of menopause, low pretreatment serum estradiol and testosterone levels, high pretreatment serum FSH levels, low pretreatment platelet MAO activity, and pretreatment mood abnormalities. We conclude that adverse mood response to the addition of a progestin occurs in menopausal women who have low pretreatment gonadal hormone levels secondary to a long duration of menopause. Impaired central nervous system adrenergic and serotonergic functioning also may be a factor predisposing to a negative mood response to progestin.

Premenstrual syndrome

Within the past decade, premenstrual syndrome (PMS) has become the subject of rigorous scientific scrutiny. As a result, diagnostic criteria have been developed, and the pathophysiology of the disorder has been partially elucidated. The preponderance of evidence suggests that the disorder is the result of the interaction of cyclic changes in estrogen and progesterone with specific neurotransmitters. Serotonin and gamma-amino butyric acid (GABA) appear to be especially important in this regard. Increased understanding of PMS has enabled the development of specific treatment modalities that, unlike previous prescriptions, have demonstrated efficacy in rigorous and reproducible studies.

Premenstrual dysphoric disorder. An update

The recent inclusion of research criteria for premenstrual dysphoric disorder (PMDD) in the DSM-IV should help physicians recognize women with symptoms of irritability, tension, dysphoria, and lability of mood which seriously interfere with their lifestyle. PMDD can be differentiated from premenstrual syndrome (PMS) which is primarily reserved for milder physical symptoms and minor mood changes. The use of DSM-IV criteria in conjunction with prospective daily charting for at least two cycles is now accepted as common practice in confirming the diagnosis. Treatment options range from conservative lifestyle and stress management to treatment with psychotropic medications and hormonal or surgical interventions to eliminate ovulation for the more extreme cases. Results from several randomized placebo-controlled trials have clearly demonstrated that selective serotonin reuptake inhibitors as well as medical or surgical oophorectomy are very effective in treating PMDD. Taken together, these data indicate that treatment may be accomplished by either eliminating the hormonal trigger or by reversing the sensitivity of the serotonergic system.

The management of treatment-resistant depression in disorders on the interface of psychiatry and medicine. Fibromyalgia, chronic fatigue syndrome, migraine, irritable bowel syndrome, atypical facial pain, and premenstrual dysphoric disorder

We have reviewed studies examining the efficacy of various psychotropic medications, primarily antidepressant agents, in the treatment of a group of disorders that appear to exhibit some phenomenologic and genetic relationship to major depression. These disorders all appear to benefit (albeit to varying degrees) from antidepressant medications of several different chemical families. This observation has important theoretical and clinical implications. From a theoretical perspective, these results invite the hypothesis that these various disorders may share some particular etiologic "step" in common with major depression-and that the various antidepressant classes benefit these various disorders and major depression via a common action at this hypothetical "step". Although there is an appealing parsimony to this hypothesis, several reservations must be considered. First, it must be recognized that the quality of the available studies varies widely. As noted in the text, these studies used numerous different designs, varying diagnostic criteria for the disorders under study, and diverse methods of rating outcome. Interpretation is further complicated by the fact that many studies included other concomitant medications or therapeutic interventions in addition to the psychotropic drugs administered. Also, the dose of antidepressant medications administered in many of these studies, especially those using TCAs, was often much less than that normally administered in the treatment of major depressive disorder itself. Finally, many of the studies did not systematically evaluate improvement in both the physical and psychological symptoms of a given disorder. For all of these reasons, any theoretic discussion of the results must be tentative. Nevertheless, the overall tally of results strongly favors the hypothesis that antidepressant agents, regardless of their chemical class, are generally useful in the treatment of these disorders. At a minimum, therefore, we can conclude that antidepressant treatment in these disorders deserves aggressive further investigation in studies with modern, rigorous designs. Second, even allowing that multiple antidepressant agents are effective in these various disorders, it still may be premature to conclude that these disorders are related to major depressive disorder. In particular, many of the studies found little correlation between improvement in psychological symptoms and physical symptoms of a given disorder. This observation would seem to argue against a relationship with major depressive disorder. The alternative hypothesis, however, namely, that these disorders do not share a common etiologic "step," seems even less attractive. It would be a remarkable coincidence if, say, fluoxetine possessed an antidepressant property, an independent antimigraine property, and a third, independent, antipremenstrual dysphoric disorder property. And it would be even more peculiar if various other antidepressant medications chemically unrelated to fluoxetine also, by chance alone, benefited all of these same disorders via still other independent mechanisms. Although we cannot, of course, rule out the possibility of multiple mechanisms and multiple causes, the experience of scientific research often has been that the simpler explanation of a phenomenon has proved to be correct. Therefore, the possibility of a link among these various antidepressant-responsive disorders deserves investigation. From a clinical perspective, too, these results are important. They suggest that trials of antidepressant medications should be strongly considered in patients with these disorders. Furthermore, other types of psychotropic medication appear to have a role in the treatment of individual disorders, as discussed in the corresponding sections.(ABSTRACT TRUNCATED)

Office gynecology for the primary care physician, part II: pelvic pain, vulvar disease, disorders of menstruation, premenstrual syndrome, and breast disease

Approaches to patients with pelvic pain, vulvar disease, disorders of menstruation, premenstrual syndrome, and breast diseases are addressed. In the great majority of cases, it is appropriate for the primary care physician to initiate evaluation and management of these problems. It is hoped that the brief introductions contained here suggest a diagnostic approach to each disorder and guide referral to consultants as needed.

Paroxetine as a treatment for premenstrual dysphoric disorder

Research into the psychobiology of premenstrual dysphoric disorder (PDD) finds alterations in markers associated with serotonergic neurotransmission. Supporting this is work showing that patients with PDD respond to some agents that block the reuptake of serotonin. In this open trial, patients were treated for one cycle with placebo and then for three consecutive cycles with the serotonin reuptake inhibitor paroxetine. The study population was composed of 14 participants who met DSM-IV criteria for PDD with moderate to severe symptomatology and specifically endorsed anger and irritability as a central premenstrual complaint. Patients showed modest improvement over the course of the pretreatment evaluation, with significant improvement occurring for feelings of worthlessness, decreased interest, and low energy. The effects of active treatment were marked by the first active cycle with luteal phase 17-item Hamilton Rating Scale for Depression scores decreasing from 14.9 (+/- 5.3) to 8.2 (+/- 4.9) in the first, 7.8 (+/- 5.1) in the second, and 7.8 (+/- 6.8) in the third active treatment cycles (F[1,13] = 17.6; p < 0.0001). A group of items from daily ratings indicative of anger and irritability (mood swings, anger and irritability, behavioral dyscontrol, and interpersonal conflicts) also showed improvement (F[1,13] = 5.94; p < 0.03). Various definitions of response were applied to treatment completers. The most conservative measure, the Clinical Global Impression (CGI), revealed that 7 of 14 patients had a complete response (CGI = 1 or 2) whereas 4 patients had a partial response (CGI = 3). These open trial findings are consistent with the notion that paroxetine is effective in the acute phase for the treatment of PDD.

The neuroendocrine response to d-fenfluramine in women with premenstrual depression

An oral d-fenfluramine neuroendocrine challenge test was carried out in 17 women with premenstrual depression and 14 controls, twice in each subject, once in the late luteal phase when mood change was likely to be at its worst (i.e. premenstrual) and once postmenstrually. Women weighing < 65 kg received 15 mg, the remainder 30 mg of d-fenfluramine. Although there was considerable individual variability, a substantial average prolactin response was observed in both groups but no phase, group or group x phase interaction effects were found. Oestradiol levels were significantly higher during the postmenstrual test but showed no relationship to prolactin response. Cortisol showed a more modest response to the drug and a phase effect was found, with cortisol increase being greater during the postmenstrual test in both groups. In contrast to earlier findings with i.v. L-tryptophan challenge, the present study failed to show any difference in neuroendocrine response between women with premenstrual depression and controls. These results suggest that 5-hydroxy-tryptophan2 receptor function is unaltered in perimenstrual mood disorder although other interpretations of the negative findings are discussed.

Hormones and depression: what are the facts about premenstrual syndrome, menopause, and hormone replacement therapy?

The diagnosis, epidemiology, etiology, and treatment of premenstrual syndrome are reviewed. A relationship between depression and premenstrual syndrome is suggested by the increased prevalence of prior depressive episodes in women with premenstrual syndrome, common neurotransmitter and chronobiologic abnormalities, and the successful treatment of premenstrual syndrome with regimens used for depression. The relationship between menopause and depression is not clearly defined, but the perimenopausal years may be a time of increased depression for women who are at risk for depressive recurrences. The role of hormone replacement treatments in either ameliorating or promoting depression in menopausal women is a subject for future studies.