Suicidal Thoughts Common in Women With PMDD

Fran Lowry

June 03, 2019

Sara Carlini, MD

SCOTTSDALE, Arizona — Both passive and active thoughts of suicide occur concurrently in a subset of women with premenstrual syndrome, new research suggests.

"Premenstrual dysphoric disorder, or PMDD, is a constellation of physical, cognitive, and affective symptoms causing clinically significant distress or interference in the 7 days before the onset of menses, after which they are minimal or go away completely," study investigator Sara Carlini, MD, from Zucker Hillside Hospital, Glen Oaks, New York, told Medscape Medical News.

"We found that rates of suicidal ideation concurrent with PMDD ranged from 11% to 32% for passive and from 9% to 23% for active suicidal ideation in our different study samples," Carlini said.

The findings were presented here at the American Society of Clinical Psychopharmacology (ASCP) 2019 annual meeting.

Urgent Issue

Suicidal ideation (SI) is not included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria for PMDD, but it should be, Carlini said.

"Epidemiological studies have shown that PMDD is associated with increased suicidal ideation, plans, and attempts, and other studies have reported increased prevalence of PMDD among female suicide attempters, with rates from 15% to 54%. This highlights the urgency of diagnosing and adequately treating this often overlooked disorder," she said.

Carlini and colleagues assessed the prevalence of passive or active suicidal ideation as a specific dimension of premenstrual syndrome, and also characterized the sample of women who experience such ideation.

To assess the prevalence of passive or active suicidal ideation as a specific dimension of PMDD, the researchers used a survey developed by the Women's Mood Disorder task group of the National Network of Depression Centers that assesses women's mood disorders across the lifespan.

The survey encompasses demographics, current anxiety as per the Generalized Anxiety Disorder (GAD-7) scale and depressive symptomatology as per the Patient Health Questionnaire (PHQ-9), current and past psychiatric diagnoses and treatments, menstrual mood, perinatal mood, perimenopausal mood, and stressors including the Adverse Childhood Experiences (ACE) questionnaire.

All women 18 years and older who were attending the outpatient psychiatry clinic, the obstetrics gynecology clinic, and those who were hospitalized in the psychiatric unit at Zucker Hillside Hospital and Long Island Jewish Medical Center were invited to take the survey.

Researchers collected a total of 256 surveys from July to November 2018. Slightly more than half (54%) of respondents had a positive screen for PMDD, and of those, 11% reported concurrent passive SI, and 9% concurrent active SI.

Rates were higher among women hospitalized in the psychiatry unit at Zucker Hillside Hospital. From the 53 surveys that were collected there, 70% of the women had PMDD. Of these, 32% reported concurrent passive SI, and 23% reported concurrent active SI.

Women attending the outpatient psychiatry clinic answered a total of 75 surveys, and 52% of those women reported having PMDD. Of these women, 13% reported concurrent passive SI, and 13% reported concurrent active SI.

In addition, there were 128 total surveys collected from women attending an outpatient obstetrics and gynecology clinic. Half of the survey respondents were positive for premenstrual symptoms and less than 1% had concurrent passive and active SI.

"I was able to isolate a cohort of women who said, 'Yes, I have premenstrual symptoms, and at that time, I have new or increased suicidal ideation.' We need to start paying more attention to this issue. Women's health issues in general don't seem to get a lot of attention, despite the fact that we're half the population," Carlini said. "This issue could be a matter of life or death."

Women who scored high on the ACE score also had higher rates of suicidal ideation of both types.

"ACE is a checklist of how many traumatic, adverse events occur in childhood. It includes not having enough to eat, physical violence, sexual abuse, having parents that were divorced, having someone in the household with a serious substance abuse problem, so it's basically a marker of how difficult the childhood was," Carlini said. 

"There is also interesting literature that suggests women with increased trauma histories are more hormone sensitive. This could be a mechanism underlying the development of PMDD overall, and also why some women suffer greater symptoms than others," she said.

PMDD Mood Symptoms a "Real" Problem

Commenting on the findings for Medscape Medical News, Anita H. Clayton, MD, David C. Wilson professor and chair of the Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, said PMDD is an important topic.

"Sometimes, we think about women having aggressive impulses, but more towards other people when they have premenstrual disorder. But we often don't ask and talk to them about passive or active suicidal ideation, and we tend to neglect the idea of irritability and self-aggression," Clayton said.

Anita H. Clayton, MD

She noted that the greater the severity of PMDD the greater the intensity of SI.

For instance, she noted that the study showed women who were hospitalized in a psychiatric unit had the highest rates of concurrent passive and active suicidal ideation, followed by those attending an outpatient psychiatry clinic, while women attending an Ob/Gyn clinic reported fewer mood symptoms associated with PMDD.

"If you think about the mood symptoms, the depression, feeling overwhelmed, irritability, and impulsivity, these could contribute to more active suicidal ideation. So PMS is not a joke, especially if you have the mood symptoms associated with it and not just the physical symptoms. Clearly it's a real problem, and the percentages in this study show that the number of women affected is not insignificant," Clayton said.

Carlini and Clayton have reported no relevant financial relationships.

ASCP 2019. Presented May 30, 2019. Abstract 3001802.

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