Can you have comorbid Premenstrual Dysphoric Disorder (PMDD) and Major Depressive Disorder (MDD)?

Comorbid PMDD and MDD: Diagnosis and Management

Yes, Premenstrual Dysphoric Disorder (PMDD) and Major Depressive Disorder (MDD) can coexist as comorbid conditions, and this comorbidity requires specific diagnostic considerations and treatment approaches.

Diagnostic Considerations

• PMDD is a distinct diagnostic entity characterized by mood symptoms that occur specifically during the luteal phase of the menstrual cycle and resolve shortly after menstruation begins 1.
• Unlike MDD, the hallmark features of PMDD are irritability and affect lability rather than persistent depressed mood 1.
• The prevalence of clinically significant PMDD is estimated at 3-8% of women of reproductive age, though up to 13-18% may experience symptoms severe enough to cause distress and impairment 2.

Distinguishing Features:

• Timing pattern: PMDD symptoms appear during luteal phase and resolve with menstruation, while MDD symptoms persist throughout the menstrual cycle.
• Primary symptoms: PMDD typically presents with irritability and mood lability as primary features, whereas MDD presents with persistent depressed mood and anhedonia.
• Functional impact: PMDD has functional impairment similar to dysthymic disorder and approaching that of MDD 2.

Diagnostic Approach

1. Symptom tracking: Prospective daily symptom charting across at least two menstrual cycles is essential to differentiate between:

   • Pure PMDD (symptoms only in luteal phase)
   • Pure MDD (symptoms consistent throughout cycle)
   • Comorbid PMDD+MDD (baseline depressive symptoms with premenstrual exacerbation)

2. Validated assessment tools:

   • Use standardized depression scales (PHQ-9, MADRS) to assess MDD symptoms
   • Use prospective daily rating scales specific to PMDD to track cyclical symptom patterns

Treatment Considerations

When PMDD and MDD coexist, treatment should address both conditions:

First-line approach:

• Serotonin reuptake inhibitors (SRIs) are first-line treatments for both PMDD and MDD 1.
  • For PMDD, SRIs often work with rapid onset (within days)
  • For MDD, SRIs typically require 4-6 weeks for full effect
  • Consider continuous rather than luteal phase-only dosing when both conditions are present

Treatment algorithm:

1. Start with an SRI (SSRI preferred) at appropriate dosing for MDD

   • Target complete remission of MDD symptoms (PHQ-9 score ≤2) 3
   • Monitor response at 4 and 8 weeks 3

2. If inadequate response:

   • Optimize SRI dose before switching or augmenting 3
   • Consider switching to sertraline if patient has psychomotor agitation or melancholic features 3
   • Consider venlafaxine if anxiety symptoms are prominent 3

3. For persistent PMDD symptoms despite MDD improvement:

   • Consider hormonal interventions (oral contraceptives) as adjunctive treatment 4
   • Add cognitive-behavioral therapy (CBT) specifically targeting premenstrual symptoms

Special Considerations

• Assess for other comorbidities: PMDD is also associated with higher rates of ADHD 5 and anxiety disorders 1.
• Monitor for bipolar disorder: Some studies suggest a link between PMDD and bipolar disorder 4. Careful assessment is needed before starting SRIs.
• Treatment resistance: If multiple treatments fail, consider specialized referral for multidisciplinary care 6.

Pitfalls to Avoid

• Misattribution of symptoms: Attributing all symptoms to either PMDD or MDD alone when both conditions exist.
• Inadequate symptom tracking: Failing to use prospective daily ratings to distinguish cyclical from persistent symptoms.
• Premature treatment changes: Not allowing sufficient time for SRIs to work for MDD while addressing PMDD symptoms.
• Overlooking hormonal interventions: Not considering hormonal treatments as adjunctive therapy when appropriate.

Remember that PMDD is not simply a variant of MDD but a distinct condition with its own treatment considerations, even when they co-occur 1. Proper diagnosis and targeted treatment of both conditions can significantly improve quality of life and functioning.