Selective serotonin reuptake inhibitors and treatment of premenstrual dysphoric disorder.

TOPIC. Premenstrual dysphoric disorder (PMDD) has reentered the spotlight following the FDA's recent approval of fluoxetine hydrochloride to treat its symptoms. Although the diagnosis and treatment of PMDD has long been a source of contention, the FDA move has heightened the debate over this diagnostic category and the most appropriate treatment. PURPOSE. To explore several diagnoses related to PMDD and review recent research findings pertaining to the effectiveness of SSRIs to treat PMDD. SOURCES OF INFORMATION. Published literature. CONCLUSIONS. Advanced practice nurses need to remain well informed about premenstrual conditions and emerging evidence-based treatment alternatives. In particular, they need to remember that the FDA has approved fluoxetine for the treatment of a very small subset of women with premenstrual complaints, among whom treatment efficacy is limited. Search terms: Fluoxetine hydrochloride, premenstrual dysphoric disorder, premenstrual syndrome, selective serotonin reuptake inhibitors ********** The Food and Drug Administration's (FDA) approval of the selective serotonin reuptake inhibitor (SSRI) fluoxetine hydrochloride (Prozac[TM] or Sarafem[TM]) to treat premenstrual dysphoric disorder (PMDD) (FDA, 2000) has put premenstrual symptoms in the spotlight. Although the diagnosis and treatment of premenstrual complaints have long been points of contention (Endicott et al., 1999; Hardie, 1997; Richardson, 1995), the FDA announcement has added fuel to a smoldering fire. This fire was ignited in 1987 when investigational criteria for premenstrual complaints were included in the appendix of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) (American Psychological Association [APA], 1987). Since that time, the diagnostic labels have changed and proliferated; clarity, however, has not been achieved. Further, unsupported treatment regimens have been promulgated (Steiner, 2000), and the effectiveness of common remedies such as analgesics and oral contraceptives has not been substantiated (Pearlstein & Steiner, 2000). Of recent concern are widely publicized, albeit confusing and inaccurate, statements regarding the supposed efficacy of medications to treat premenstrual symptoms. For instance, the following misleading pronouncement was located on a Web site devoted to women's health concerns. "[T]he efficacy of pharmacologic treatment in women with PMS is firmly established" (Mortola, 1997, p. 4). As is discussed in this article, the following is a more accurate statement: Emergent findings suggest that selective medications may be helpful in the treatment of premenstrual symptoms among a very small minority of severely affected women; ideal prescribing practices and long-term outcomes, however, have not been determined. Given the FDA approval of fluoxetine for the treatment of premenstrual complaints and the frequent misdiagnosis and labeling of problems related to the premenstruum, the remainder of this article focuses on the assessment, differential diagnosis, potential etiology, and treatment and research concerns related to premenstrual conditions. In particular, the focus is on PMDD, as it is one of the most misunderstood and controversial of the premenstrual conditions. Nosology of Premenstrual Symptoms Many consumers and some healthcare providers believe there is a well-delineated and singular condition known as premenstrual syndrome. Despite the prevalence of this assumption, it is not partnered with a unified set of diagnostic criteria. In fact, experts have proposed six separate sets of criteria for problems related to the premenstruum, all of which are casually referred to as premenstrual syndrome. The plethora of labels that abound to describe premenstrual complaints have been part of the healthcare lexicon for only about 40 years. …