Study: Premenstrual mood changes predictive of greater bipolar disorder severity

A study of nearly 300 women with bipolar disorder showed that those reporting flare-ups of mood symptoms before menstruation had more depressive episodes and more severe symptoms during the following year, compared with bipolar women without premenstrual mood changes.

The study was part of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) and was conducted by Rodrigo Dias, M.D., and colleagues at Massachusetts General Hospital in Boston. The report will be published online at AJP in Advance, the online advance edition of The American Journal of Psychiatry, the official journal of the American Psychiatric Association.

The study results provide evidence that premenstrual mood exacerbation may be a clinical marker predicting a worse presentation and course of bipolar disorder in reproductive-age women. The authors note that estrogen and other reproductive hormones influence mood symptoms through their action in the central nervous system. In women with bipolar disorder, the time following childbirth and the menopause transition are also periods of increased vulnerability to illness relapse. The susceptibility of mood to fluctuating hormone levels may result in greater mood instability in general.

The number of diagnosed illness episodes differed only for depressive episodes, not those characterized by mania or hypomania. Also, the women with premenstrual exacerbations were no more likely to have the extreme form of bipolar disorder known as rapid cycling (defined as four or more episodes per year). They did, however, have shorter gaps between symptomatic intervals.

Dr. Dias pointed out the implications for clinical practice: "The results reinforce the importance of identifying mood fluctuations across the menstrual cycle in women with bipolar disorder. The women with premenstrual mood changes may benefit from more intensive monitoring. The value of antidepressants isn't clear, since on the one hand, these women were less likely to be taking antidepressants and might have benefited from them, but on the other hand, antidepressants can trigger manic symptoms in bipolar patients."

The article will appear on Feb. 15 at AJP in Advance. STEP-BD is funded by the National Institute of Mental Health; this study was funded in part by a donation from the Thompson Motta Family to the Bipolar Research Program, Institute of Psychiatry of the Hospital das Clinicas, University São Paulo Medical School. Financial support received by the individual authors is reported in the article.