2003, Number 3
Comparación entre el tratamiento continuo y el intermitente con citalopram para el trastorno disfórico premenstrual
Flores RM, Ontiveros UM, Cortés SJ
Full text
Language: Spanish
References: 46
Page: 37-45
PDF size: 390.91 Kb.
ABSTRACT
Premenstrual dysphoric disorder (PMDD) includes emotional, physical and behavioral symptoms appearing a few days before menstruation, and decreasing at its beginning. The mood symptoms –such as irritability, depressed mood and emotional lability– are prominent and cause social, laboral and interpersonal impairment. Often these symptoms are accompanied by various somatic complaints, such as breast tenderness and a sense of bloating. To be defined as PMDD, the symptoms should appear regularly after ovulation or within the 2 weeks prior to the menstruation and are completely absent during follicular phases. According to DSM-IV criteria of PMDD, the diagnosis must be confirmed by daily symptom rating for two symptomatic menstrual cycles, that is, the diagnosis will be made in a prospective way. Etiology of this disorder is not still clear, but the symptoms cyclicity is related to the hormonal status, therefore it is believed that sex steroids are involved in the cause of PMDD. Moreover premenstrual complaints can be abolished by inhibition of ovarian function, and revived by the administration of sex steroids, it is believed that the interaction of the neurotransmission and hormonal systems can explain the dysfunction, and the role of serotonin in PMDD is important to be considered. Approximately 80 types of therapeutic interventions have been suggested to treat this syndrome, including hygienic-dietetic measures, diuretics, hormonal agents and antidepressives. Of all these, the selective serotonin reuptake inhibitors (SSRI) are the best studied, and have shown its effectiveness for treating this problem. Controversy has been centered in evaluating the treatment administered only during the symptomatic phase; this has been called intermittent treatment. Actually there are reports that support intermittent treatment, and others that consider that continuous treatment is better. It is thought that in spite of the similarity with depression, the response to this type of antidepressant is faster in PMDD. With regard to personality, some studies found elevated neuroticism scores in women that suffer PMDD, but some of these reports were made in the premenstrual phase when high symptoms levels may influence personality assessment, suggesting that the high neuroticism could be consequence of the illness. Moreover, antidepressant treatment effects in personality traits have not been investigated in this disorder.Objective
This work evaluates continuous treatment response vs intermittent treatment response to citalopram in patients with PMDD and the personality traits of those patients.
Method
Patients were recruited at “Instituto Nacional de Psiquiatría” in Mexico City. All the patients gave explicit written informed consent for the treatment. A psychiatric interview was carried out by a psychiatrist to make a presumptive diagnosis, and then a second interview was made by the psychiatrist responsible for this study to confirm diagnosis. At this time it was realized a clinical history, emphasizing gynecobstetrics and psychiatric antecedents. Basic laboratory test and electrocardiogram were realized. Later patients were evaluated with Moos Menstrual Diary during 2 consecutive menstrual cycles. Patients with follicular symptoms and no ratings exacerbation in the luteal phase according the scale were excluded. Twenty three patients with PMDD, according to the DSM-IV were included. All patients should be having regular menstrual cycles, no hormonal treatment and no contra-indications for using citalopram. Patients with endocrine or gynecological illness, pregnant or during lactation, with any other diagnosis of axis I, including substance abuse disorder, were excluded from the study.
No psychotropics were permitted at least six months before beginning the study. Twenty three patients were randomly included in two groups: Twelve received citalopram 20 mg/day during the previous week to menstruation, and 11 received citalopram 20 mg/day during the whole menstrual period. Patients in the intermittent group received placebo during three weeks in identical capsules. Neither the patients nor the psychiatrist knew to which treatment group had the patients been assigned. Moos Menstrual Diary was applied during 2 menstrual cycles after the treatment begun. Hopkins Symptom Check List (SCL-90) and Eysenck Personality Questionnaire (EPQ) were also applied in the follicular and in the luteal phase, at baseline and at the end of the treatment.
Patient’s visits took place according to their menstrual cycle at follicular and luteal phase during two consecutives menstrual cycles.
Improvement was evaluated after two follow-up menstrual cycles, and was defined by a decrement of at least 10 points in Moos Menstrual Diary ratings. Statistical analysis: MANOVA was realized to evaluate the Moos scores through the time according the group. Multivariate analysis was made with three variables: group (intermittent vs continuous), time (basal vs final) and phase (follicular vs luteal). T test for independent variables was used to analyze neuroticism scores with respect to time and treatment group.
Results
Nineteen patients completed the study and were included in the statistical analysis: ten in the intermittent group and nine in the continuous group. There were not differences in socio-demographic characteristics in the groups. Neither differences were observed in the clinical characteristics. At baseline punctuations in the intermittent group were more elevated than punctuations in the continuous group, but it was product of randomization. Premenstrual symptomatology decreased both in women receiving continuous treatment and in women receiving intermittent treatment, although more significantly in the continuous group: nevertheless these differences were not statistically significant.
Twelve patients were respondents, of these 66.6% were receiving continuous treatment and 33.3% were receiving intermittent treatment, this difference was statistically significant and confirmed the superiority of continuous treatment. The SCL-90 scale yielded differences in depression and anxiety scores, obviously both decreased with treatment. In both groups, the initial scores of neuroticism were elevated and decreased significantly at the end of the treatment. Collateral effects more reported were nausea, dry mouth and diarrhea but in general, citalopram was well tolerated by all the patients.
Conclusions
Results suggest that patients with PMDD improve with continuously administered citalopram, although previous studies have reported a good response to intermittent treatments. In this study we observed higher basal punctuations in Moos in patients which were assigned at intermittent group, and this could represent a bias. It is important to note that neuroticism scores decreased with both treatments.
REFERENCES