If you suffer from the debilitating symptoms of PMDD, also known as premenstrual dysphoric disorder, it may surprise you to learn that up until now, it has been at the margins—or, more accurately, in the appendix—of mainstream psychological thinking in the U.S. That’s because the formal guide to the diagnosis of mental illness, the DSM-IV, listed PMDD at the back of the book, in its appendix, where conditions that the psychiatric profession wasn’t sure about were listed. Now, PMDD appears to be poised to join other recognized illnesses and conditions in the main section of the upcoming new DSM-V.
If you’ve been diagnosed with PMDD, or wondered if you have PMDD, you might be a little disconcerted to learn that it is considered a mental illness – but for any condition to be treated by medical doctors with psychiatric medications like Prozac® or Sarafem® (Fluoxetine®) and other SSRIs, it has to be listed in the DSM and is then called a mental illness.
The downside of this, of course, is that there is a social stigma associated with the word “mental illness.” Many people don’t realize that by itself, it is just a label that doesn’t really mean anything, and that millions of people have depression and other “mental” illnesses that we now understand are physical ailments like any other – they just happen to affect the brain, instead of joints or kidneys or other structures.
One potential upside to PMDD’s promotion to the main section of the DSM-V, up from the appendix, is an increased recognition of premenstrual dysphoric disorder, with more attention to research and investigation on possible causes and cures likely to follow.
An interesting side note: with an increasing recognition of PMDD, there will be a tendency for general practitioners to make this diagnosis, even though gynecologists and psychiatrists are probably more familiar with the condition, its diagnostic criteria, and how to manage it. PMDD can’t be diagnosed in your typical 5-15 minute doctor’s visit.
Another evolving factor to keep an eye on: it is now recognized at the highest levels of research and medicine that SSRIs—selective serotonin reuptake inhibitors, like Prozac®, Sarafem® and Zoloft®—don’t work for depression through helping with serotonin levels in the brain. In fact, they don’t work any differently than placebo, a fact that is causing tremendous reverberations in the world of mental health.
This may not be true for PMDD: since it hasn’t been studied, we don’t know if SSRIs work differently in PMDD than they do in depression. But this is unlikely, since the use of Fluoxetine® for PMDD grew out of the similarities between depression and what used to be called late luteal phase disorder. So as the whole paradigm of serotonin deficiency begins to crumble, the treatment of PMDD may change too—perhaps just in time for the DSM-VI.
Antidepressants like Sarafem®, Prozac®, and Zoloft® are the most commonly prescribed medications for PMDD and PMS. In fact, if you’ve talked to a doctor or done a little internet research about PMDD and PMS, there’s a good chance you’re already familiar with the use of the selective serotonin reuptake inhibitor (SSRI) class of drugs for the treatment of PMDD and severe PMS.
We discussed previously how Sarafem® was brought to market for PMS only after the patent on Prozac was about to expire, and that before Sarafem®, PMDD was not a household word. And, of course, like all medications, antidepressant side effects are a real concern.
Recently an even more important question has come to the forefront, accentuated by the recent New York Times Magazine article by Siddhartha Mukherjee which discussed, among other things, the research of the Ph.D. psychologist Irving Kirsch, who conducted groundbreaking research showing that SSRI antidepressants do not work much better than placebo (sugar pill.) Kirsch also found that the drug companies and the FDA suppressed negative studies of SSRI antidepressants, and this resulted in a skewed and overly optimistic estimate of their effects. At this point, the the research on SSRIs adds up to one unavoidable conclusion: most of the prescriptions for Prozac®, Zoloft®, and similar drugs are of questionable utility, because these drugs don’t work significantly better than placebo for mild and moderate depression. SSRIs do work well for serious, major depression.
This brings us to the important question of whether SSRI antidepressants for PMDD and PMS are a good idea. Do they work? Are they better than placebo? How can we tell which woman really needs antidepressants for PMDD, and who doesn’t? Is the risk of side effects worth the risk of trying a medication that may be no better than sugar pill?
The answer to the first question is yes – antidepressants work for PMDD. The tricky part is that it is now a clear scientific fact that for mild and moderate depression, antidepressants aren’t superior to placebo, so it is unlikely that they are better than placebo for severe PMS and PMDD. But the real crux of the issue is the third question: how does anyone know if antidepressants are the right choice?
There is no way to determine this answer based on blood tests or a doctor’s exam. This important decision must be based on the severity of the symptoms, as determined by both the prescribing health care practitioner, and the patient. Do the symptoms resemble those of major depressive disorder? Are they truly debilitating and oppressive so that they are major impediment to functioning in the world, living life, and fulfilling one’s role and responsibilities?
There are certainly cases of major depression that meet these criteria, and they often respond to the SSRI antidepressants. Similarly, we can expect that when PMDD symptoms are so severe that they might as well be major depressive disorder for days to weeks out of the month, SSRIs are appropriate.
However, as we referenced earlier, SSRI antidepressants have side effects, and many women prefer to avoid them. When PMS and even PMDD symptoms fall short of the kind of interference with living that major depression causes, there are a wealth of excellent alternatives that have few side effects; are effective, and more effective than placebo; and that in some cases have been shown to be as effective as antidepressants.
Women and doctors should consider diet and stress management, as well as other lifestyle factors, as effective PMS & PMDD therapies. Proven remedies like Vitex agnus-castus, or Chasteberry; calcium; magnesium; and vitamin B6 as first line natural PMDD treatments that can be used before, or even instead of, antidepressants. Other supplements and herbs such as B-complex vitamins; the herbs Dong Quai and Black Cohosh; and the problems of food allergy and hypoglycemia are all worth adding to the list of natural PMDD alternatives.
We all know drugs can be real lifesavers. And we probably all know someone who, at one time or another, felt like an antidepressant prescription lifted them out of a rough patch in their life, or even changed their life. But the widespread use of prescription antidepressants is starting to make some psychiatrists nervous, as they have become the third most common prescribed class of drug, with sales of over $11 Billion (!) in 2010.
A recent study, published in the journal Health Affairs, that came with some heavyweight credentials—Johns Hopkins, Columbia University, the Agency for Healthcare Policy and Research, and Eli Lilly, the big pharma corporation—found that 80% of those antidepressant prescriptions are being written by non-psychiatrists, and that more and more of them are being given for non-psychiatric uses such as PMS and chronic pain.
PMDD, otherwise known as premenstrual dysphoric disorder, can be considered both a gynecologic and a psychiatric condition. In today’s health care environment, we can’t blame a gynecologist for prescribing antidepressants for PMDD or severe PMS rather than referring to a psychiatrist. But the study left little doubt that these medications are being overprescribed by medical practitioners who may not fully understand these drugs, their side effects, or how to manage patients taking them.
All of which leads us to wonder, at least as it relates to PMS, PMDD, and antidepressants, why so many doctors and health care practitioners don’t understand how safe and effective natural, holistic PMS remedies actually are:
Diet: There are foods that are bad for PMS such as caffeinated beverages (decaf coffee still contains caffeine, so your reaction will depend on your sensitivity), alcohol, and refined sugar; foods that are good for PMS, like whole grains, leafy greens, broccoli, flax, and soy; and overall dietary factors like food sensitivities or allergies, and blood sugar instability, also called hypoglycemia, that can actually cause PMS. We suspect that most doctors who write antidepressant prescriptions for PMS don’t discuss the healing role of diet in adequate detail. Lifestyle: Lifestyle choices, good and bad, can have a significant impact on PMS symptoms. Premenstrual syndrome has been proven to be connected with cigarette smoking, weight, and stress. And exercise is one of the most tried and true natural PMS relief remedies. Supplements and nutrition: Several nutrients, taken as supplements, are known to help PMS, like vitamin B6, magnesium, and calcium. But nutrients work together, so we shouldn’t forget the other B vitamins, or vitamin D, or essential minerals like zinc and chromium. We’re pretty sure most doctors aren’t extolling the virtues of a high-potency multivitamin as they write their prescriptions! Herbal supplements: Certain herbs are safe, effective, and downright invaluable for treating PMS. Chastetree Berry and Dong Quai are among the most commonly used, though there are others we like as well. It is too bad that so many doctors don’t trust herbal medicine, despite its record of safety as well as the large amount of research showing its efficacy for PMS.
We are thrilled that modern science has created the wonder drugs and technology that are able to help so many people. But we do wish there was a trend towards a greater recognition of the role diet and lifestyle changes, and natural remedies could play in decreasing the need for antidepressants and other pharmacological medications.