How should I manage suicidal thoughts that arise during my menstrual period, possibly related to premenstrual dysphoric disorder?

Management of Suicidal Thoughts During Menstruation

If you are experiencing suicidal thoughts during your period, you need immediate psychiatric evaluation to determine if you have premenstrual dysphoric disorder (PMDD) and require urgent safety assessment, with selective serotonin reuptake inhibitors (SSRIs) as first-line treatment once the diagnosis is confirmed. 1, 2, 3

Immediate Safety Assessment

Suicidal thoughts should never be dismissed as unimportant, regardless of their timing in your menstrual cycle. 1 You need immediate evaluation to determine your level of risk:

• High-risk indicators requiring immediate hospitalization include: persistent wish to die, specific suicide plan, recent suicide attempt, severe hopelessness, agitation, or inability to participate in safety planning 1, 4
• Ask yourself or have someone ask you directly: "Have you ever thought about killing yourself or wished you were dead?" followed by "Have you ever done anything on purpose to hurt or kill yourself?" 1
• Safety takes precedence over confidentiality - if you are at risk to yourself, others must be informed to ensure your safety 1

Establishing the Diagnosis

You must track your symptoms prospectively for at least two menstrual cycles to confirm PMDD, as symptoms can vary cycle to cycle. 5 PMDD is characterized by:

• Mood symptoms (depressed mood, anxiety, irritability), somatic symptoms (bloating, breast tenderness, overeating), or cognitive symptoms (forgetfulness, difficulty concentrating) that begin several days before menses, improve within a few days after menses starts, and become minimal or absent within one week of menses onset 1
• Symptoms must substantially interfere with work, school, social activities, or relationships or cause significant distress to meet criteria for PMDD rather than premenstrual syndrome 5
• Use the Daily Record of Severity of Problems (a validated prospective survey tool) to document the cyclic pattern 5

Environmental Safety Measures

Immediately remove all firearms from your home and secure all medications (prescription and over-the-counter). 1, 4 This is non-negotiable:

• Firearms are the most common method adolescents and young adults use to complete suicide 1
• Medication ingestion is the most common method used for suicide attempts 1
• Parents or household members must be explicitly told to remove firearms and lethal medications - do not rely on the patient alone to do this 1
• Alcohol and other drugs have dangerous disinhibiting effects that increase suicide risk 1

First-Line Pharmacological Treatment

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for PMDD with rapid onset of improvement. 2, 3, 5, 6 The approach differs from depression treatment:

• SSRIs can be effective when used cyclically, only during the luteal phase (the two weeks before your period), or even limited to the duration of monthly symptoms - they do not need to be taken daily 2
• This is unlike depression treatment where daily dosing is required 2
• SSRIs reduce suicidal ideation in adults with mood disorders and are safe with low lethality in overdose 1
• Common SSRIs include fluoxetine, sertraline, paroxetine, and citalopram 2, 3
• Monitor carefully for new suicidal ideation or akathisia (restlessness) when starting SSRIs, as there have been rare reports of disinhibiting effects 1

Second-Line Treatment Options

If SSRIs are ineffective or not tolerated:

• Oral contraceptives containing drospirenone can suppress ovulation and reduce PMDD symptoms 6
• Calcium supplementation (1200 mg daily) has evidence for reducing premenstrual symptoms 3, 6
• Vitex agnus castus (chasteberry) may ameliorate symptoms 5, 6
• Cognitive behavioral therapy (CBT) has data supporting benefit and should be added to medication treatment, as it reduces suicidal ideation, behavior, and hopelessness 7, 4, 3, 5

Ongoing Monitoring and Follow-Up

Close follow-up is essential even if you seem at lower risk, as the absence of high-risk factors does not guarantee low risk. 1

• Schedule definite, closely-spaced follow-up appointments initially 8
• The treating clinician should be available outside therapeutic hours or have adequate coverage to manage suicidal crises 1
• Track symptoms prospectively each cycle to assess treatment response 5
• If symptoms persist throughout the month despite treatment, reassess for another underlying cause such as major depressive disorder or bipolar disorder 5

Critical Pitfalls to Avoid

• Do not rely on "no-suicide contracts" - these have no proven value and should not reduce vigilance 1
• Do not prescribe benzodiazepines if you have suicidal thoughts with impulsivity, as these reduce self-control 4
• Do not use tricyclic antidepressants as first-line treatment - they are potentially lethal in overdose and not proven effective in younger patients 1
• Do not dismiss suicidal thoughts as "just hormonal" - PMDD is a recognized psychiatric disorder requiring treatment 1