Reviewer’s report
Title: 
Prevalence and correlates of current suicidal ideation in women with
premenstrual dysphoric disorder
Version: 
1 
Date: 
25 Aug 2021
Reviewer's report:
This is a well-written, novel study that examines whether prospectively-
diagnosed PMDD is associated with luteal phase suicidal ideation and explores
covariates associated with suicidal ideation. The study employs rigorous, gold-
standard methodology for diagnosing PMDD, and the study's utilization of two
cycles of daily ratings to confirm PMDD diagnoses sets it apart from prior
literature exploring the association between provisional PMDD diagnoses and
suicidal ideation. Although topic is of critical importance to the readers of this
journal, there are several points that require revision as listed below. 
1. The authors test whether a variety of sociodemographic and psychological
characteristics were associated with the odds of reporting suicidal ideation, but
did not provide a priori hypotheses for any of these associations. It would be
helpful to clarify whether these analyses were exploratory or hypothesis-driven,
and, if the latter, more explanation should be included to clarify the rationale and
expected direction of effects in both the introduction and discussion.
Furthermore, given the number of seemingly exploratory analyses, authors
should correct for multiple comparisons to ensure the robustness of the observed
effects. 
2. Although not described in the text, the table indicates that 4 of the participants
were using hormonal contraceptives at the time of the study. Given the fact that
many hormonal contraceptives may prevent ovulation or alter cycling hormone
levels, which in turn may impact hormone-related mood symptoms in diverse
ways, these individuals should be excluded from the analyses. Alternatively,
sensitivity analyses should be conducted without these individuals to examine
whether the primary effects hold and the limitations of including these
individuals should be discussed. 
3. As mentioned above, the use of two cycles of prospective daily ratings in this
study is a strength and a significant advancement from prior studies in this area.
The paper would be strengthened by an explanation of the importance of
prospective diagnosis in the introduction, including the fact that PMDD
diagnosis based on retrospective self-report is prone to false positives and is
likely only weakly associated with prospective PMDD diagnosis (see Eisenlohr-
Moul et al., 2016 in The American Journal of Psychiatry). 
4. While the authors generally describe the impairment and distress experienced
by those with PMDD, the introduction and discussion would be strengthened by
a more in-depth exploration of why PMDD might be associated with increased
risk for suicidal ideation, particularly in the luteal phase. Although this study
does not test mechanisms of this association, it may be helpful to briefly
summarized current hypothesized biological and/or psychological mechanisms
of this association (e.g. Owens et al. 2018, Current Psychiatry Reports). 
5. Authors appropriately include inclusion and exclusion criteria, but do not
describe how the study was advertised or the language used in recruitment
materials. Although the sample is confined to those with prospectively-
confirmed PMDD, it would be helpful to know whether the sample self-selected
into a study advertised as being about PMDD, in order to help readers
understand the representativeness of the present sample. 
6. It would be helpful to include a brief discussion of the limitations of
restricting the sample to exclude those with any comorbid disorders, particularly
given the high prevalence of comorbid disorders among those diagnosed with
PMDD in the general population. 
7. More information about the administration instructions and psychometric
properties of the MADRS-S, especially relative to other measures of suicidal
ideation, given that the primary outcome of interest is based on a single item
from this measure.
8. Given the finding that previous psychological treatment for PMDD was
associated with greater risk for suicidal ideation, it would be helpful to include a
more detailed description or table of the types of psychological treatment if
available (e.g. whether or not evidence-based treatments were used). 
In sum, I believe this paper explores an interesting and novel theoretical question
of great interest to clinicians and the field as a whole. In order for the results to
be interpretable, however, I believe it is critical that the authors clarify the
characteristics of their sample as described above, and provide additional
background information about the importance of prospective diagnosis for
PMDD and the hypothesized association between PMDD and suicide. With
these minor revisions, I believe this paper has the potential to significantly
advance an understanding of the relationship between PMDD and suicidal
ideation. 
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes