Title: A DSM-5-based tool to monitor concurrent mood and premenstrual symptoms: The
McMaster Premenstrual and Mood Symptom Scale (MAC-PMSS)
Version: 2 Date: 01 Feb 2022
Reviewer:  Jennifer L. Gordon
Reviewer's report:
This manuscript reports preliminary findings suggesting that the McMaster Premenstrual and
Mood Symptom Scale (MAC-PMSS) is a valid and useful tool for concurrently assessing
symptoms of PMDD as well as symptoms of major depressive disorder and/or bipolar disorder.
This research helps to fill a gap in the assessment of comorbid PMDD and mood disorders as the
MAC-PMSS is the first tool of its kind. I therefore read the manuscript with great interest and
believe it will be a valuable addition to the literature. However, I also believe the manuscript
can be improved in a number of important ways, which I outline below.
Introduction
1. The introduction would benefit from quite a bit of editing to be more precise in its language.
“Premenstrual syndrome” is not a valid diagnosis – it is therefore unclear what it means to “meet
criteria for PMS”. Anytime the term “PMS” or “premenstrual mood dysregulation” is used,
more specific language should replace it. Furthermore, my understanding of the literature is that
approximately 13-19% of women experience what would be considered clinically significant but
sub-threshold symptoms of PMDD (e.g., fewer than 5 symptoms show sufficient exacerbation
in the premenstrual phase) – 30-40% seems quite high and I would question the validity of the
definition of “PMS” used in that study.
2. Please specify the prevalence rate of premenstrual exacerbation of mood disorders and explain
how it is defined/calculated in the literature.
3. The first sentence of the introduction is quite misleading and potentially contributes to the
common (and damaging) misconception that most women suffer from clinically significant
mood symptoms in the premenstrual phase.
Methods
4. The manuscript would benefit from more details about the sample recruited – how many
participants were from each clinic vs. the community? What did community advertisements say?
How many prospective participants were deemed ineligible (and why) or refused to participate?
5. What was the protocol for reminding participants to complete the MAC-PMSS? Was it
completed as a paper and pencil form (vs. online survey) across the board?
6. How many experts was the MAC-PMSS distributed to during the pilot? How many patients
participated in the pilot?
7. The Carolina Premenstrual Assessment Scoring System (C-PASS) (Eisenlohr-Moul et al.
(2017). Am J Psychiatry, 127:1) would seem like a more objective system for determining
PMDD diagnosis than the methods used in this study. Also, the C-PASS recommends a 30%
increase in symptoms in the premenstrual phase rather than the 50% cut-off used in the current
study.
Results
8. I would suggest using the term “provisional diagnosis of PMDD” when describing cases
in which DSM criteria appeared to be met but were not yet confirmed with prospective daily
ratings.
9. One of the major potential uses of this tool is to assess premenstrual exacerbation (PME) of
mood disorders. I’m therefore surprised that there is no examination of PME. How prevalent was
it in this sample and how does this prevalence compare to other studies of PME? In my mind,
this should be a major component of this manuscript and should be discussed in the discussion
section.
10. More information should be given regarding participant acceptability – how consistently
did participants complete the MAC-PMSS? This is another point that should be included in the
discussion section.
Discussion
11. One third of provisional PMDD diagnoses were confirmed through prospective daily ratings
– please discuss how this compares with other studies.
12. The discussion is quite short and would benefit from further discussion of clinical
implications and recommendations for future research. Do the researchers recommend this
tool replace the DRSP or only be used in patients with an established mood disorder? Do the
researchers consider this tool ready to be disseminated widely as it is or are further validations
studies needed?