I am a reproductive‑age woman taking about 150 g protein supplement daily and citalopram 10 mg for depression; I have persistent low mood, anxiety, worsening symptoms during the luteal phase with bloating, irritability, night‑time hot flashes and difficulty concentrating, and I wonder if I might have ADHD and what medication options would be appropriate?

Premenstrual Dysphoric Disorder (PMDD) with Possible ADHD

Primary Diagnosis: PMDD, Not ADHD

Your symptoms—worsening mood, anxiety, irritability, bloating, and difficulty concentrating specifically during the luteal phase (premenstrual period)—are classic for premenstrual dysphoric disorder (PMDD), not ADHD. 1 ADHD symptoms are present continuously across the menstrual cycle, whereas your symptoms clearly worsen only around menstruation. 1

Key Distinguishing Features

• PMDD: Symptoms emerge 1–2 weeks before menses, resolve within days of menstrual onset, and include mood lability, irritability, anxiety, bloating, and concentration difficulties that are time-locked to the luteal phase. 1
• ADHD: Symptoms are chronic and pervasive across all settings and times of the month, not cyclical. 1
• Your description of feeling "more down when on period" with bloating, irritability, and hot flashes at night strongly suggests PMDD rather than ADHD. 1

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Recommended Treatment: Optimize Your Current SSRI

Increase citalopram from 10 mg to 20–40 mg daily, as your current dose is subtherapeutic for both depression and PMDD. 2, 3

Evidence for SSRI Dose Optimization

• Citalopram 40–60 mg/day demonstrates robust efficacy for depressed mood and melancholia, with statistically significant superiority over placebo. 2
• Escitalopram (the active S-enantiomer of citalopram) at 10–20 mg/day shows significant improvement within 1 week, with 10 mg escitalopram equivalent to 40 mg citalopram. 3
• Your current 10 mg citalopram dose is at the very low end of the therapeutic range and unlikely to control PMDD symptoms. 2, 3

Titration Protocol

• Increase citalopram to 20 mg daily for 2 weeks, then to 40 mg if symptoms persist. 2
• Monitor for nausea, insomnia, and somnolence—the most common side effects—which typically resolve within 1–2 weeks. 2, 3
• Steady-state plasma levels are reached within 7–10 days, so reassess symptoms after 2–3 weeks at each dose. 4

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Why Not ADHD Medication?

Do not pursue stimulant therapy for ADHD until you have optimized treatment for PMDD and depression, as untreated mood disorders can mimic ADHD symptoms. 1

Critical Reasoning

• Around 10% of adults with recurrent depression/anxiety have comorbid ADHD, but treating mood symptoms alone often restores optimal functioning when ADHD is not truly present. 1
• Your concentration difficulties occur specifically during the luteal phase, suggesting they are secondary to PMDD-related mood and anxiety symptoms rather than primary ADHD. 1
• If ADHD symptoms persist after 6–8 weeks of optimized SSRI therapy (citalopram 40 mg), then formal ADHD screening with the Adult ADHD Self-Report Scale (ASRS) Part A is warranted. 1

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Addressing Night-Time Hot Flashes

Hot flashes at night in a reproductive-age woman taking citalopram may represent SSRI-induced night sweats or perimenopausal symptoms; however, they are also consistent with PMDD-related autonomic dysregulation. 2

Management Approach

• Increased sweating is a known side effect of citalopram, occurring in >5% of patients. 2
• If hot flashes persist after optimizing citalopram, consider switching to escitalopram 10–20 mg, which has a more favorable side-effect profile with lower rates of sweating. 5, 3
• Monitor for resolution of hot flashes as PMDD symptoms improve with higher SSRI doses. 2

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Monitoring and Follow-Up

Week 1–2 (Citalopram 20 mg)

• Track mood, anxiety, irritability, and concentration daily using a symptom diary to identify luteal-phase patterns. 1
• Monitor for nausea, insomnia, and increased sweating. 2, 3

Week 3–4 (Citalopram 40 mg if needed)

• Reassess PMDD symptoms across at least one full menstrual cycle. 1
• If concentration difficulties persist outside the luteal phase, complete the ASRS screening tool. 1

Week 6–8

• If PMDD symptoms are controlled but ADHD symptoms remain, consider adding a stimulant (methylphenidate or lisdexamfetamine) to the SSRI regimen, as there are no significant drug-drug interactions. 1
• Stimulants achieve 70–80% response rates and work within days, allowing rapid assessment of ADHD symptom response. 1

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Common Pitfalls to Avoid

• Do not assume ADHD based on luteal-phase concentration difficulties alone—this is a hallmark of PMDD, not ADHD. 1
• Do not add stimulant therapy before optimizing SSRI treatment—untreated depression and PMDD will persist and worsen functional impairment. 1
• Do not switch SSRIs prematurely—the STAR*D trial showed no difference in response rates when switching from one SSRI to another; dose optimization is more effective. 1
• Do not discontinue citalopram abruptly—taper gradually to prevent discontinuation syndrome. 1