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Original Investigation |

Symptom-Onset Dosing of Sertraline for the Treatment of Premenstrual Dysphoric Disorder A Randomized Clinical Trial

Kimberly A. Yonkers, MD1,2,3; Susan G. Kornstein, MD4,5; Ralitza Gueorguieva, PhD6; Brian Merry, MS1; Kari Van Steenburgh, BA1; Margaret Altemus, MD7
[+] Author Affiliations
1Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
2Department of Obstetrics, Yale University School of Medicine, New Haven, Connecticut
3Department of Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
4Department of Psychiatry, Virginia Commonwealth University, Richmond
5Institute for Women’s Health, Virginia Commonwealth University, Richmond
6Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
7Department of Psychiatry, Weill Cornell Medical College, New York, New York
JAMA Psychiatry. 2015;72(10):1037-1044. doi:10.1001/jamapsychiatry.2015.1472.
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Importance  Serotonin reuptake inhibitors (SRIs) are efficacious treatments for premenstrual dysphoric disorder (PMDD) when given daily or for half of the menstrual cycle during the luteal phase. Preliminary studies suggest that SRI treatment can be shortened to the interval from symptom onset through the beginning of menses.

Objective  To determine the efficacy of symptom-onset dosing with the SRI sertraline hydrochloride for treatment of PMDD.

Design, Setting, and Participants  A double-blind, placebo-controlled, multisite, parallel-group randomized clinical trial conducted September 1, 2007, to February 29, 2012, at 3 university medical centers. In all, 252 women with PMDD started treatment at symptom onset and continued until the first few days of menses for 6 menstrual cycles. Intent-to-treat analyses were performed February 28, 2014, through April 21, 2015.

Interventions  Placebo or sertraline hydrochloride, 50 to 100 mg/d, during the symptomatic interval.

Main Outcomes and Measures  Premenstrual Tension Scale (PMTS) score was the primary outcome measure (score range, 0-36; 36 indicates most severe score). Secondary outcome measures included the Inventory of Depressive Symptomatology–Clinician-Rated (IDS-C) (score range, 0-84; 84 indicates most severe score), Daily Record of Severity of Problems (DRSP) (total and subscale scores; higher scores indicate most severe problems), Clinical Global Impression (CGI) scales (score range, 1-7; 7 indicates most severe symptoms and least improvement), and Michelson SSRI (Selective SRI) Withdrawal Symptoms Scale scores (range, 0-51; higher scores indicate more severe withdrawal symptoms).

Results  Among the participants, 125 with PMDD were randomized to sertraline, and 127 to placebo. At baseline the mean (SD) PMTS scores for sertaline and placebo were 22.3 (4.8) and 21.4 (4.5), respectively, which declined to 11.7 (6.8) and 12.0 (6.9), respectively; group mean difference, 1.88 (95% CI, 0.01-3.75; P = .06). The mean (SD) estimated difference in IDS-C scores between baseline (35.4 [10.7] for sertraline; 32.8 [10.4] for placebo) and the end point (15.3 [10.7] for sertraline; 17.8 [11.0] for placebo) favored the sertraline group by 5.14 (95% CI, 1.97-8.31) points (P = .02). Compared with the placebo group, those assigned to sertraline showed greater improvement on the total DRSP score (estimated mean difference, 1.09 [95% CI, 0.96-1.25] points; P = .02) and Anger/Irritability DRSP subscale score (1.22 [95% CI, 1.05-1.41] points; P < .01) and were more likely to respond to treatment (77 of 115 patients [67.0%] for sertraline and 65 of 124 [52.4%] for placebo; χ21 = 5.23; P = .02). The mean (SD) number of symptomatic days before treatment diminished over time (sertraline, −0.7 [3.4] days; placebo, −1.0 [3.2] days), with no group differences in symptomatic days or the Michelson SSRI Withdrawal Symptoms Scale.

Conclusions and Relevance  Depending on the symptom scale, women with PMDD may or may not benefit from SRI treatment during the interval from the onset of premenstrual symptoms through the first few days of menses. Abrupt treatment cessation was not associated with discontinuation symptoms.

Trial Registration  clinicaltrials.gov Identifier: NCT00536198

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aIncludes those who could not be located and those who were unwilling to attend.

bRandomization occurred between signing of informed consent and the baseline visit. Randomization was not disclosed to the participant.

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