Fourth consensus of the International Society for Premenstrual Disorders (ISPMD): auditable standards for diagnosis and management of premenstrual disorder.

Whilst professional bodies such as the Royal College and the American College of Obstetricians and Gynecologists have well-established standards for audit of management for most gynaecology disorders, such standards for premenstrual disorders (PMDs) have yet to be developed. The International Society of Premenstrual Disorders (ISPMD) has already published three consensus papers on PMDs covering areas that include definition, classification/quantification, clinical trial design and management (American College Obstetricians and Gynecologists 2011; Brown et al. in Cochrane Database Syst Rev 2:CD001396, 2009; Dickerson et al. in Am Fam Physician 67(8):1743-1752, 2003). In this fourth consensus of ISPMD, we aim to create a set of auditable standards for the clinical management of PMDs. All members of the original ISPMD consensus group were invited to submit one or more auditable standards to be eligible in the inclusion of the consensus. Ninety-five percent of members (18/19) responded with at least one auditable standard. A total of 66 auditable standards were received, which were returned to all group members who then ranked the standards in order of priority, before the results were collated. Proposed standards related to the diagnosis of PMDs identified the importance of obtaining an accurate history, that a symptom diary should be kept for 2 months prior to diagnosis and that symptom reporting demonstrates symptoms in the premenstrual phase of the menstrual cycle and relieved by menstruation. Regarding treatment, the most important standards were the use of selective serotonin reuptake inhibitors (SSRIs) as a first line treatment, an evidence-based approach to treatment and that SSRI side effects are properly explained to patients. A set of comprehensive standards to be used in the diagnosis and treatment of PMD has been established, for which PMD management can be audited against for standardised and improved care.

ISPMD consensus on the management of premenstrual disorders.

The second consensus meeting of the International Society for Premenstrual Disorders (ISPMD) took place in London during March 2011. The primary goal was to evaluate the published evidence and consider the expert opinions of the ISPMD members to reach a consensus on advice for the management of premenstrual disorders. Gynaecologists, psychiatrists, psychologists and pharmacologists each formally presented the evidence within their area of expertise; this was followed by an in-depth discussion leading to consensus recommendations. This article provides a comprehensive review of the outcomes from the meeting. The group discussed and agreed that careful diagnosis based on the recommendations and classification derived from the first ISPMD consensus conference is essential and should underlie the appropriate management strategy. Options for the management of premenstrual disorders fall under two broad categories, (a) those influencing central nervous activity, particularly the modulation of the neurotransmitter serotonin and (b) those that suppress ovulation. Psychotropic medication, such as selective serotonin reuptake inhibitors, probably acts by dampening the influence of sex steroids on the brain. Oral contraceptives, gonadotropin-releasing hormone agonists, danazol and estradiol all most likely function by ovulation suppression. The role of oophorectomy was also considered in this respect. Alternative therapies are also addressed, with, e.g. cognitive behavioural therapy, calcium supplements and Vitex agnus castus warranting further exploration.

Impact of urbanization on mental health and well being.

PURPOSE OF REVIEW: It is predicted that by mid-21st century, over two-thirds of the world population will be urban. The shift from rural to urban living causes a major shift in priorities of public health. The current article aims at illuminating the urbanization process, its challenges and ramifications for mental health and well being of urban dwellers. RECENT FINDINGS: Currently, 55% of world population resides in urban areas. By 2050, that percentage will be at least 68%, mostly in developing and emerging economies. Adequate mental health and socioeconomic support services for the new urban migrants are almost nonexistent. SUMMARY: Adequate psychosocial clinics are an absolute urgent necessity in the neighborhoods where new migrants reside. Governments' policies and funding should be re-prioritized. For effective advocacy, descriptive comprehensive interdisciplinary epidemiological data should be an initial step of research. This should be followed by investigations of the biopsychosocial-economic causes and processes, which would point to adequate culturally sensitive practical solutions.

Well-being: Diversified perspectives in search of operational definitions.

well-being is a multi-faceted concept that should be an operational domain. The territory is claimed by many disciplines and professionals who usually emphasize their own unique perspective. Economists and politicians focus on finance, prosperity, per-capita product and jobs. Socially-minded activists focus on poverty, education, personal safety, quality of life, equality and disparities. Law-enforcement focuses on crime. Many health and Medical professionals see their patients mostly through the stethoscope, lab tests and imaging. Psychologists stress stressors, crises and their consequences. Psychiatrists see mental, emotional and cognitive disorders. clergy and philosophers emphasize spirituality, beliefs and cultural values.All are correct! Their outlooks are intertwined with each other and should be integrated into a single well-rounded comprehensive operational entity.

Premenstrual symptoms in young adults born preterm at very low birth weight--from the Helsinki Study of Very Low Birth Weight Adults.

BACKGROUND: Clinically significant premenstrual symptoms are common among young women. Premenstrual syndrome (PMS) is characterized by emotional, behavioural and physical symptoms that consistently occur during the luteal phase of the menstrual cycle. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS. Individual variation in stress responsiveness may be involved in the pathophysiology of premenstrual symptoms. Preterm birth at very low birth weight (VLBW, < 1500g) has a multitude of consequences that extend to adult life, including altered stress responsiveness which could affect the prevalence of premenstrual symptoms. METHODS: In this cohort study, we compared 75 VLBW women with 95 women born at term (mean age 22.5). We used a standardized retrospective questionnaire assessing the presence and severity of a variety of symptoms before and after menses. The symptom scores were used both as continuous and as dichotomized variables, with cutoffs based on DSM-IV criteria for PMDD and ACOG criteria for PMS, except prospective daily ratings could not be used. We used multiple linear and logistic regression to adjust for confounders. RESULTS: There was no difference in the continuous symptom score before menses (mean difference VLBW-term -18.3%, 95% confidence interval -37.9 to 7.5%) or after menses. The prevalence of premenstrual symptoms causing severe impairment to daily life was 13.3% for VLBW women and 14.7% for control women. For PMDD, it was 8.0% and 4.2%, and for PMS, 12.0% and 11.6%, respectively. These differences were not statistically significant (p > 0.1). CONCLUSION: Our findings suggest that the severity of premenstrual symptoms and the prevalence of PMDD and PMS among young women born preterm at VLBW is not higher than among those born at term.

Towards a consensus on diagnostic criteria, measurement and trial design of the premenstrual disorders: the ISPMD Montreal consensus.

Premenstrual disorders (PMD) are characterised by a cluster of somatic and psychological symptoms of varying severity that occur during the luteal phase of the menstrual cycle and resolve during menses (Freeman and Sondheimer, Prim Care Companion J Clin Psychiatry 5:30-39, 2003; Halbreich, Gynecol Endocrinol 19:320-334, 2004). Although PMD have been widely recognised for many decades, their precise cause is still unknown and there are no definitive, universally accepted diagnostic criteria. To consider this issue, an international multidisciplinary group of experts met at a face-to-face consensus meeting to review current definitions and diagnostic criteria for PMD. This was followed by extensive correspondence. The consensus group formally became established as the International Society for Premenstrual Disorders (ISPMD). The inaugural meeting of the ISPMD was held in Montreal in September 2008. The primary aim was to provide a unified approach for the diagnostic criteria of PMD, their quantification and guidelines on clinical trial design. This report summarises their recommendations. It is hoped that the criteria proposed here will inform discussions of the next edition of the World Health Organisation's International Classification of Diseases (ICD-11), and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) criteria that are currently under consideration. It is also hoped that the proposed definitions and guidelines could be used by all clinicians and investigators to provide a consistent approach to the diagnosis and treatment of PMD and to aid scientific and clinical research in this field.

Psychosocial stress and immunosuppression in cancer: what can we learn from new research?

It is generally believed that the physiological consequences of stress could contribute to poor outcomes for patients being treated for cancer. However, despite preclinical and clinical evidence suggesting that stress promotes increased cancer-related mortality, a comprehensive understanding of the mechanisms involved in mediating these effects does not yet exist. We reviewed 47 clinical studies published between 2007 and 2020 to determine whether psychosocial stress affects clinical outcomes in cancer: 6.4% of studies showed a protective effect; 44.6% showed a harmful effect; 48.9% showed no association. These data suggest that psychosocial stress could affect cancer incidence and/or mortality, but the association is unclear. To shed light on this potentially important relationship, objective biomarkers of stress are needed to more accurately evaluate levels of stress and its downstream effects. As a potential candidate, the neuroendocrine signalling pathways initiated by stress are known to affect anti-tumour immune cells, and here we summarise how this may promote an immunosuppressive, pro-tumour microenvironment. Further research must be done to understand the relationships between stress and immunity to more accurately measure how stress affects cancer progression and outcome.

Stressors and mental health in Bangladesh: current situation and future hopes.

Bangladesh is a densely populated emerging country in South Asia. Since its harsh independence war, it has suffered from repeated floods and other natural and man-inflicted disasters. Internal migration from rural areas to the urban centres has increased crowdedness, pollution and social conflicts. Furthermore, in recent years, the country has absorbed close to a million refugees from Myanmar. These stressors have been associated with an increase in mental disorders and symptoms with which the country is struggling. Lack of resources and a shortage of human capital have weakened the national capacity to efficiently respond to situational stressors or disasters. For assessment of stress-related mental health issues, information available from the Ministry of Health and the National Institute of Mental Health was collected and supplemented by external reports. It is promising that the government's approach of responding to mental health needs only after the occurrence of a crisis has recently been replaced by the concept of total management through primary healthcare. There is a need for development of adequate infrastructure, logistics and workforce support, as well as establishment of multidisciplinary teams of management and clinical services. Collaboration of all related sectors of the government and an overall increase in government funding for mental health are essential.

Psychological distress and sleep problems in healthcare workers in a developing context during COVID-19 pandemic: Implications for workplace wellbeing.

BACKGROUND: Emotional wellbeing of healthcare workers is critical to the quality of patient care, and effective function of health services. The corona virus disease-2019 (COVID-19) pandemic exerted unique physical and emotional demands on healthcare workers, however little is known about the emotional wellbeing of healthcare workers during the COVID-19 pandemic in resource-restricted settings. This study investigated the prevalence of psychological distress, and sleep problems in healthcare workers in a COVID-19 referral hospital in Nigeria. METHODS: A total of 303 healthcare workers were interviewed with the 12-item General Health Questionnaire (GHQ-12) to evaluate psychological distress, and the Pittsburgh Sleep Quality Index (PSQI) to assess multidimensional aspects of sleep, including quality, latency, duration, habitual efficiency, disturbances, use of sleeping medications and daytime dysfunction. RESULTS: The participants were mostly males, 183(60.4%) and mean age was 38.8(SD = 8.9) years. Most of the participants were married (70.3%), had spent less than 10 years in service (72.9%), and had no medical comorbidity (92.1%). The prevalence of psychological distress was 23.4%, and six in every ten participants reported sleep problems. The largest proportion of participants reported difficulty in sleep latency (81.5%), duration (71.3%), and daytime dysfunction (69.6%), while approximately one third (32%) each reported using sleep medication, and had difficulty with sleep quality. Psychological distress was inter-related with poor sleep problems (p = 0.001; effect size = 0.2). CONCLUSION: The prevalence rates of psychological distress and sleep problems during the COVID-19 pandemic were several folds the rates previously reported in similar contexts. Preventative psychosocial support services for healthcare workers are indicated. The creation of a culturally-sensitive interdisciplinary blueprint for locally-viable actions model are strongly suggested ahead of future emergency situations.

Non-Western therapies for affective disorders: in pursuit of open-minded considerations of concepts and applications.

INTRODUCTION: Complementary and alternative medicine (CAM) modalities are gaining popularity among patients in Western countries. They are especially popular among patients seeking treatment for mental and mood symptoms. Some CAMs are according to current Western approaches but have not achieved approval by regulatory agencies. Some other modalities are according to non-Western concepts of mental order and disorder. This installment of "The Well-Rounded Brain" will illuminate some non-Western concepts with an example of treatment modality for affective disorders, and compare them to conventional Western approach. METHODS: Principles of the Chinese concept of affective disorders and acupuncture modalities for their treatments are briefly described from a culturally sensitive perspective. RESULTS: Traditional Chinese medicine and current conventional Western medicine substantially differ in underlying concepts, development of treatment modalities, as well as their goals and implementation. CONCLUSION: Some non-Western concepts and treatment modalities have been meticulously and rigorously developed through trial and error, though the evidence for their efficacy and efficiency is not necessarily according to current Western standards. The consistent epidemiological demonstrations of the demand for CAM among patients suffering from mental disorders call for an open-minded, unbiased assessment of efficacy of non-Western treatment modalities for specific clusters of affective symptoms.

Grave Concerns Expressed by Psychiatrists Over Current Immigration Policies.

As members of the Global Mental Health and Psychiatry Caucus of the American Psychiatric Association (APA), we would like to express our grave concerns about the ongoing policies and treatment of asylum seekers, refugees, and immigrants coming to the United States, and the adverse mental health sequelae that such policies will have on these individuals and populations.

Partnerships for interdisciplinary collaborative global well-being.

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. The multifaceted intertwined nature of optimal health, mental health, and well-being requires operational, sustainable interdisciplinary partnerships in order to improve personal and global well-being and happiness. The initial step must be the assessment of the nature and magnitude of local problems in the global context. The WHO annual reports may be an adequate departure point as they can demonstrate the global nature of stressful situations and their association with physical and mental stress-related disorders. Therein, mental health professionals should spearhead change and progress. Attitudes need to be pro-active and partnerships are essential. Pertinent data should be evaluated by local experts who will determine the needs and how best to face them and achieve solutions. Hopefully, common regional denominators will lead to the formation of Regional Interdisciplinary Collaborative Alliances (RICAs) who will share needed resources and focus particularly on vulnerable populations. The RICAs would be supported by experts and technological facilities located in developed economy centers. The long-term goal is to turn the concept of pursuit of happiness into a well-perceived reality.

Selective serotonin reuptake inhibitors and initial oral contraceptives for the treatment of PMDD: effective but not enough.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are almost unanimously considered to be very efficacious and the first line of pharmacologic treatment for premenstrual dysphoric disorder (PMDD) and premenstrual syndrome (PMS). There is a need to examine if this is actually the case. More recently, combined oral contraceptives (COCs) have been pursued due to their ovulation suppression effects. Their effects on PMS/PMDD should be further examined as well. METHODS: For this review of the literature from 1990 to the present, MEDLINE, PsychLit, and Cochrane controlled trials register were searched. Randomized, double-blind, placebo-controlled clinical trials of SSRIs and COCs (N>20) that report the rate of responders and not just percent improvement in severity of symptoms were selected for study. The data extraction were the percentage or number of responders as reported by the original authors. RESULTS: In many studies, only mean improvement in severity was reported. In all studies, the main inclusion criterion was meeting criteria for PMDD; this has not, however, been an outcome measure. However, only 16 reports that provided actual rate of responders could be included. The percentage of non-responders (100% minus active medication) to SSRIs and COCs was found to be higher than the reported percentage of women who responded to active medication (response rate to an SSRI or COC minus the response rate to placebo). CONCLUSION: In the majority of larger-scale studies, once the placebo effect is accounted for, the percentage of women who respond to SSRIs or COCs is actually less than the percentage of women who do not respond at all. SSRIs provide an important step forward in the treatment of PMDD and PMS. COCs provide a different option, still, approximately 40% of women with PMDD do not respond to SSRIs. Treatment with a currently approved COC does not substantially improve the percentage of responders. Therefore, additional alternative targeted treatment modalities need to be developed.

Participation in clinical trials may improve care of acute schizophrenia inpatients in a general hospital.

INTRODUCTION: This report demonstrates parameters of quality of care and treatment outcome of acute schizophrenia patients who were involved as subjects in a clinical trial of two marketed widely used antipsychotics compared with their fellow patients who received routine clinical hospital care. METHODS: Patients were newly admitted severely agitated schizophrenia patients who agreed to participate in a double-blind randomized trial of short-term (5 days) rate of improvement in response to two second-generation oral antipsychotics. Treatment outcomes as measured by the Clinical Global Impression and parameters of quality of care were compared with the general population of inpatients in the same county hospital. RESULTS: Of 145 patients screened, 109 patients did not meet study inclusion and exclusion criteria. It is of note that systematic diagnostic interview did not confirm the clinical diagnosis of schizophrenia in 17 patients (11.7%). Study patients had shorter length of stay (6.75 days vs 15.3 days of total psychiatric patients at the hospital during the study period), no physical restraints (vs 21.9%), no use of antipsychotics as chemical restraints (vs 19.8%), and less recidivism following the trial (28.1%) compared with prior to the trial (64.3%). CONCLUSION: Patients who participate in structured clinical research with well-delineated procedures, clinical outcome measures, and clear expectations, fared better than their fellow patients in the same non-research hospital wards. Application of some characteristics of clinical research to the diagnosis and treatment of clinical non-research patients may be considered.

Osteoporosis, schizophrenia and antipsychotics: the need for a comprehensive multifactorial evaluation.

Osteoporosis is recognised as a major public health issue leading to bone fractures, pain and disability. Awareness of an elevated risk of osteoporosis in individuals with schizophrenia is increasing. An accelerated decrease in bone mineral density (BMD) in patients with schizophrenia may be disease related or drug induced. A drug-induced decrease in BMD has been attributed mostly to hyperprolactinaemia and its consequences. However, as demonstrated in this review, decreased BMD and osteoporosis are multifactorial processes, and abnormal bone structure and functions are not limited to BMD. Multiple dynamic processes may lead to impairment of bone homeostasis and eventually to bone abnormalities. Many of these processes may be abnormal in treated as well as untreated patients with schizophrenia. Despite many publications, the epidemiology of abnormal bone structure, mineralisation and dynamics in patients with schizophrenia is still not fully determined. Comprehensive studies of bone dynamics in individuals with first-episode schizophrenia, as well as in patients treated with various current medications, are needed in order to characterise the problem(s) and then to develop relevant treatment and prevention strategies.

Atypical depression, somatic depression and anxious depression in women: are they gender-preferred phenotypes?

BACKGROUND: Both depression and anxiety disorders affect women at rates significantly greater than men. Women also have a documented higher frequency of comorbid depression and anxiety disorders, and a three-fold higher prevalence of atypical depression. HYPOTHESES: These gender differences are mainly due to specific depressive phenotypes including anxious depression and atypical depression. The prevalence of comorbid anxiety and depression strongly suggests overlap of pathophysiological mechanisms-which in women are also affected by fluctuations in gonadal hormones. Similar efficacy of serotonergic antidepressants as treatment for anxiety disorders as well as depressions further underscores the blurred boundaries between these two descriptive entities. CONCLUSIONS: Symptoms of depression and anxiety may be a departure point for differential diagnosis in which dimensionally-based phenotypes substantiated by pathobiology would replace current descriptive entities. It is suggested that at least some biologically-based dysphorias may be specific to women, ensuing from the combination of specific vulnerabilities, and complex interactions between brain mechanisms and gonadal hormones.

Effects of electroacupuncture and fluoxetine on the density of GTP-binding-proteins in platelet membrane in patients with major depressive disorder.

BACKGROUND: Electroacupuncture (EA) has been used to treat Major Depressive Disorder (MDD). However, its efficacy is inconclusive and the mechanism is still unclear. Thus, the objective of this study is to investigate the therapeutic effect of EA on GTP-binding-protein (G protein) in platelet membrane using fluoxetine as a comparison. METHODS: A randomized controlled trial (RCT) was performed on 90 MDD patients, who were divided into three groups treated with fluoxetine, EA and sham EA respectively. Antibodies were utilized to quantify the levels of G protein alpha subtypes in the platelet membrane before and after 6-week anti-depressive treatment. Thirty age and sex-matched normal individuals were used as controls. RESULT: All the treatments had the same therapeutic effects in treating moderate depression. Both levels of Galphai and Galphaq in depression patients were significantly higher than those in controls and were not reduced by treatments, although the severity was considerably relieved. LIMITATIONS: The duration of treatment was limited to six weeks only. CONCLUSION: EA might be served as an alternative treatment for moderate depression and we further demonstrate that the abnormal levels of Galpha protein in platelet membrane might be a potential risk factor for MDD.

Culturally-sensitive complaints of depressions and anxieties in women.

BACKGROUND: Current classifications of Mental Disorders are centered on Westernized concepts and constructs. "Cross-cultural sensitivity" emphasizes culturally-appropriate translations of symptoms and questions, assuming that concepts and constructs are applicable. METHODS: Groups and individual psychiatrists from various cultures from Asia, Latin America, North Africa and Eastern Europe prepared descriptions of main symptoms and complaints of treatment-seeking women in their cultures, which are interpreted by clinicians as a manifestation of a clinically-relevant dysphoric disorder. They also transliterated the expressions of DSM IV criteria of main dysphoric disorders in their cultures. RESULTS: In many non-western cultures the symptoms and constructs that are interpreted and treated as dysphoric disorders are mostly somatic and are different from the Western-centered DSM or ICD systems. In many cases the DSM and ICD criteria of depression and anxieties are not even acknowledged by patients. LIMITATIONS: The descriptive approach reported here is a preliminary step which involved local but Westernized clinicians-investigators following a biomedical thinking. It should be followed by a more systematic-comprehensive surveys in each culture. CONCLUSIONS: Westernized concepts and constructs of mental order and disorders are not necessarily universally applicable. Culturally-sensitive phenomena, treatments and treatment responses may be diversified. Attempts at their cross-cultural harmonization should take into consideration complex interactional multi-dimensional processes.

Major depression is not a diagnosis, it is a departure point to differential diagnosis -- clinical and hormonal considerations (a commentary and elaboration on Antonejevic's paper).

Currently, the prevailing diagnostic systems of mental disorders, including Depressions and anxieties are based on descriptive phenomenological approach and not on etiology and pathophysiology. However, cumulative knowledge suggests that the field is moving towards establishment of subtypes or phenotypes of depressions based on different pathophysiologies, which may result in differential treatment responses. What is currently defined as 'Major Depressive Disorder (MDD)' may be the end-result of multiple heterogeneous biological and psychosocial processes. Therefore, MDD is actually a first step towards a differential diagnosis that eventually may lead to pathophysiology-based entities. Several hormonal systems may play a major role in the pathophysiology of several subtypes of depressions and anxieties. They include but are not limited to dysregulation of the hypothalamic-pituitary-adrenal (HPA) system, HP-Gonadal (HPG) and Thyroid (HPT) systems as well as their interactions with immune and other biological and psychosocial processes. Elucidation of the multiple underlying mechanisms of depressions and anxieties should lead to targeted treatment modalities and improvement of treatment responses.

Are there differential symptom profiles that improve in response to different pharmacological treatments of premenstrual syndrome/premenstrual dysphoric disorder?

Current evidence suggests that the accepted treatments for premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) have similar overall efficacy. While these treatments are more effective than placebo, response rates associated with them are far from satisfactory (<60%), such that, irrespective of treatment modality, there remain a significant number of women who are unresponsive to current conventional pharmacological therapy. The available data on response rates of specific types of premenstrual symptoms to, or symptom profiles that are most amenable to, each treatment modality are limited and not well defined because most studies were not designed to assess specific symptom profiles. Those studies that have attempted to evaluate which symptom profiles respond to specific therapies have revealed variations within the individual modalities, as well as between the different modalities. It appears that suppression of ovulation ameliorates a broad range of behavioural as well as physical premenstrual symptoms. SSRIs are most effective for irritability and anxiety symptoms, with lesser efficacy for 'atypical' premenstrual symptoms. GABAergic compounds are most efficacious for anxiety and anxious/depressive symptoms, while dopamine agonists, particularly bromocriptine, are perhaps most efficacious for mastalgia. Overall treatment response rates may improve if treatments are targeted at well-defined subgroups of patients. Re-analysis of available datasets from randomised clinical trials may shed more light on the notion that targeting women with specific premenstrual symptom profiles for specific treatment modalities would improve response rates beyond the current ceiling of approximately 60%. Such information would also improve understanding of the putative pathophysiological mechanisms underlying PMS and PMDD, and may point to a more specific diagnosis of these conditions.