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.
There’s a very good chance that you’ve never met anyone who was diagnosed with PMDD—premenstrual dysphoric disorder—before 2001. That’s because PMDD was almost unheard of before August 2001, when Prozac (Fluoxetine) went off patent. The Eli Lilly drug company responded by rebranding (a fancy drug company word for renaming) their bestselling antidepressant as Sarafem. They then began promoting Sarafem, and the very concept of PMDD, to consumers, gynecologists, psychiatrists, and general practitioners. This is a common strategy in the pharmaceutical industry: when a drug is about to go off patent, it is repackaged into a different color and shape of pill, usually, and promoted for a related but previously underutilized purpose.
Some have accused Eli Lilly of “inventing” PMDD, which is certainly untrue: there are research papers on PMDD going back as far as 1987. Although this is the year the FDA approved the marketing and sales of Prozac, there’s no reason to think that that research was related to the release of the drug. Shortly after it hit the market, doctors from many disciplines were thrilled with the effectiveness of Fluoxetine, and were exploring its use for many conditions. It’s quite logical that it was tested for severe PMS, because previous generations of anxiolytics and antidepressants had been prescribed for PMS before that.
Still, if not for Eli Lilly’s interest in extending their Fluoxetine franchise, there can be little doubt that PMDD would not be anywhere as recognizable as it is today.
At PMS Comfort, we are all for greater recognition of PMS, especially severe PMS, and PMDD. However, a mistaken belief has taken hold across the medical universe, among researchers, doctors, and patients that PMDD and PMS are completely separate conditions. They’re not. The main difference between them is that PMDD received a very clear medical definition in the 4th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), while PMS received a weak definition in 2000 that has never been updated. Since medical doctors understandably embrace clear diagnostic criteria, and because there are now drugs approved for the treatment of PMDD, it has an imprint of legitimacy that PMS does not seem to have.
But you only need to just scratch the surface to see that there is major overlap between their possible symptoms, and to realize that both PMDD and moderate to severe PMS, by definition, interfere with life and living. This is a source of confusion: while mild PMS is a mere annoyance, moderate to severe PMS interferes with women’s lives to a similar degree as PMDD. In fact, they're really not separate conditions. We wish more medical professionals were aware of this fact, because it might help women understand it also.
We are at the forefront of those trying to get PMS and PMDD the recognition, understanding, and compassion they deserve: unfortunately, too much of the wrong kind of attention gets focused on them. And we are pleased that more and more women are realizing that drugs aren’t the only answer for premenstrual symptoms. Natural and holistic treatments are safe, effective, and were never patented in the first place.