International Association for Women's Mental Health (IAWMH): World Congress on Women's Mental Health

BOGOTÁ, COLOMBIA – Adolescent girls who become pregnant and carry to term experience high morbidity, including psychiatric outcomes, numerous studies have established. And, in Latin America, teenage pregnancy rates are rising, and legal abortion is rarely an option.

Learning how to prevent postpartum depression and psychosis among these girls is something "gleaned over years of clinical practice," says Dr. Roberto Chaskel, who has treated such girls for nearly 3 decades. "No one tells you how."

At the fourth International Congress of Medicine and Women’s Mental Health, Dr. Chaskel presented video of an 11-year-old who had just given birth days earlier by cesarean section and was experiencing psychosis. The girl had been referred for psychiatric care only after the birth.

Adolescent pregnancies have risen in many Latin American countries in recent decades, despite declining fertility trends overall, according to a 2007 United Nations Report. One Latin American study of 854,377 girls aged 15 years and younger found pregnancy associated with a fourfold higher risk of a host of adverse pregnancy outcomes, including maternal death, early neonatal death, and anemia, compared with women aged 20 years or older (Am. J. Obstet. Gynecol. 2005;192:342-9).

(Meanwhile, the Centers for Disease Control and Prevention reported recently that teenage pregnancy rates in the United States declined 9% from 2009 to 2010, which means that the rate is at an historic low of 34.3 births/1,000 adolescents aged 15-19 years. The decline was seen across all ethnicities.)

In most Latin American countries, including Colombia – where access to abortion is highly restricted, pregnancies among girls aged 15 years and younger often result in birth. Only three Caribbean or Latin American states permit abortion without regard to reason, according to a 2012 report by the Guttmacher Institute. Illegal procedures are estimated to represent 95% of all abortions performed in the region, according to the same report.

In 2006, in Bogotá there were 22,228 pregnancies reported among teenage girls between 10 and 19 years of age (170/100,000), placing Bogotá’s teenage pregnancy rates nearly on nearly on par with those of Uganda and Sierra Leone, according to a 2010 study by researchers at the Universidad Nacional de Colombia. A tenth of the reported pregnancies were to women aged 14 years and younger.

It is possible to prevent psychotic and depressive episodes related to pregnancy and birth and "offer teenagers and adolescents, and the babies of these girls, the best possible quality of life" through a family practice that seeks to mitigate some of the traumas associated with early sex, pregnancy, and birth, and also to guide the early attachment process between mothers and children, said Dr. Chaskel of the department of psychiatry at the Universidad El Bosque and coordinator of child psychiatry at the Fundación Santa Fe, both in Bogotá, Colombia,.

In a separate presentation at the congress, Dr. Marta B. Rondón, a psychiatrist affiliated with the Universidad Peruana Cayetano Heredia in Lima, Peru, discussed the difficulty of achieving an evidence-based understanding of the mental health impact of abortion and unwanted pregnancy in nations where access is restricted and "generally speaking, a woman cannot choose just to terminate a nondesired pregnancy."

In a restricted legal environment, "the condition of secrecy means the woman has to go a very hard road – this could have negative consequences for her mental health – but we don’t have the numbers," Dr. Rondón said, adding that discussing how to conduct research on abortion and mental health in Latin America would be a priority of next year’s international congress on women’s mental health, which will be held in Lima.

Any attempt to get a perspective on the mental health impact of abortion and unwanted pregnancy means using studies conducted in the United States and Europe – different cultural environments that could produce different results. "We need prospective research with randomized samples in Latin America, which may become possible as abortion is gradually decriminalized," Dr. Rondón said.

Currently, Peru and Colombia allow legal abortion only in the event of a threat to the life or physical health of the woman. In addition, Colombia allows terminations in cases of rape or to preserve a woman’s mental health.

Dr. Chaskel said in an interview that the 11-year-old patient in his video would have been a candidate for legal abortion under Colombian law and that he would have referred her had she presented to him early. However, he said, her obstetrician had judged her ineligible.

Their options might be limited in terms of a choice to terminate, but pregnant adolescents in Latin America do have the benefit of strong family ties, and Dr. Chaskel’s practice taps into the high level of familial support available to most. "You bring grandma and grandpa, and the new uncles and aunts into clinical practice – right into the office," he said in an interview. A pregnancy in adolescence "generates confusion not only for the girl but also on the whole family group: In Latin America, this usually means three generations confused as to how to approach this situation."

The initial goal of the interventions, he said, is to help pregnant adolescents avoid postpartum depression and psychosis. The longer-term goal is to allow them to continue in their adolescence as normally as possible after the birth, while developing a healthy attachment to the child with the support of their families.

"Are they going to keep listening to Lady Gaga? If you have an 18-month-old baby, how do you behave? We’ve really worked on recuperating adolescence for these girls to make sure that they do listen to Lady Gaga," he said. "We try to make sure that if they’re going to have the baby, to know what they want to do – go back to school, go to a friend’s 15th birthday party [Quinceañera], or have one themselves.

"We think it over together."

After the birth, infants and their young mothers are observed and evaluated interacting in-office, where such details as the distance the child crawls away from the mother is measured as a way of gauging healthy attachments. The girls, who are at high risk of having second babies while still in their teenage years, need to be followed up for years.

Neither Dr. Chaskel nor Dr. Rondón reported disclosures.

BOGOTÁ, COLOMBIA – Adolescent girls who become pregnant and carry to term experience high morbidity, including psychiatric outcomes, numerous studies have established. And, in Latin America, teenage pregnancy rates are rising, and legal abortion is rarely an option.

Learning how to prevent postpartum depression and psychosis among these girls is something "gleaned over years of clinical practice," says Dr. Roberto Chaskel, who has treated such girls for nearly 3 decades. "No one tells you how."

At the fourth International Congress of Medicine and Women’s Mental Health, Dr. Chaskel presented video of an 11-year-old who had just given birth days earlier by cesarean section and was experiencing psychosis. The girl had been referred for psychiatric care only after the birth.

Adolescent pregnancies have risen in many Latin American countries in recent decades, despite declining fertility trends overall, according to a 2007 United Nations Report. One Latin American study of 854,377 girls aged 15 years and younger found pregnancy associated with a fourfold higher risk of a host of adverse pregnancy outcomes, including maternal death, early neonatal death, and anemia, compared with women aged 20 years or older (Am. J. Obstet. Gynecol. 2005;192:342-9).

(Meanwhile, the Centers for Disease Control and Prevention reported recently that teenage pregnancy rates in the United States declined 9% from 2009 to 2010, which means that the rate is at an historic low of 34.3 births/1,000 adolescents aged 15-19 years. The decline was seen across all ethnicities.)

In most Latin American countries, including Colombia – where access to abortion is highly restricted, pregnancies among girls aged 15 years and younger often result in birth. Only three Caribbean or Latin American states permit abortion without regard to reason, according to a 2012 report by the Guttmacher Institute. Illegal procedures are estimated to represent 95% of all abortions performed in the region, according to the same report.

In 2006, in Bogotá there were 22,228 pregnancies reported among teenage girls between 10 and 19 years of age (170/100,000), placing Bogotá’s teenage pregnancy rates nearly on nearly on par with those of Uganda and Sierra Leone, according to a 2010 study by researchers at the Universidad Nacional de Colombia. A tenth of the reported pregnancies were to women aged 14 years and younger.

It is possible to prevent psychotic and depressive episodes related to pregnancy and birth and "offer teenagers and adolescents, and the babies of these girls, the best possible quality of life" through a family practice that seeks to mitigate some of the traumas associated with early sex, pregnancy, and birth, and also to guide the early attachment process between mothers and children, said Dr. Chaskel of the department of psychiatry at the Universidad El Bosque and coordinator of child psychiatry at the Fundación Santa Fe, both in Bogotá, Colombia,.

In a separate presentation at the congress, Dr. Marta B. Rondón, a psychiatrist affiliated with the Universidad Peruana Cayetano Heredia in Lima, Peru, discussed the difficulty of achieving an evidence-based understanding of the mental health impact of abortion and unwanted pregnancy in nations where access is restricted and "generally speaking, a woman cannot choose just to terminate a nondesired pregnancy."

In a restricted legal environment, "the condition of secrecy means the woman has to go a very hard road – this could have negative consequences for her mental health – but we don’t have the numbers," Dr. Rondón said, adding that discussing how to conduct research on abortion and mental health in Latin America would be a priority of next year’s international congress on women’s mental health, which will be held in Lima.

Any attempt to get a perspective on the mental health impact of abortion and unwanted pregnancy means using studies conducted in the United States and Europe – different cultural environments that could produce different results. "We need prospective research with randomized samples in Latin America, which may become possible as abortion is gradually decriminalized," Dr. Rondón said.

Currently, Peru and Colombia allow legal abortion only in the event of a threat to the life or physical health of the woman. In addition, Colombia allows terminations in cases of rape or to preserve a woman’s mental health.

Dr. Chaskel said in an interview that the 11-year-old patient in his video would have been a candidate for legal abortion under Colombian law and that he would have referred her had she presented to him early. However, he said, her obstetrician had judged her ineligible.

Their options might be limited in terms of a choice to terminate, but pregnant adolescents in Latin America do have the benefit of strong family ties, and Dr. Chaskel’s practice taps into the high level of familial support available to most. "You bring grandma and grandpa, and the new uncles and aunts into clinical practice – right into the office," he said in an interview. A pregnancy in adolescence "generates confusion not only for the girl but also on the whole family group: In Latin America, this usually means three generations confused as to how to approach this situation."

The initial goal of the interventions, he said, is to help pregnant adolescents avoid postpartum depression and psychosis. The longer-term goal is to allow them to continue in their adolescence as normally as possible after the birth, while developing a healthy attachment to the child with the support of their families.

"Are they going to keep listening to Lady Gaga? If you have an 18-month-old baby, how do you behave? We’ve really worked on recuperating adolescence for these girls to make sure that they do listen to Lady Gaga," he said. "We try to make sure that if they’re going to have the baby, to know what they want to do – go back to school, go to a friend’s 15th birthday party [Quinceañera], or have one themselves.

"We think it over together."

After the birth, infants and their young mothers are observed and evaluated interacting in-office, where such details as the distance the child crawls away from the mother is measured as a way of gauging healthy attachments. The girls, who are at high risk of having second babies while still in their teenage years, need to be followed up for years.

Neither Dr. Chaskel nor Dr. Rondón reported disclosures.

BOGOTÁ, COLOMBIA – Adolescent girls who become pregnant and carry to term experience high morbidity, including psychiatric outcomes, numerous studies have established. And, in Latin America, teenage pregnancy rates are rising, and legal abortion is rarely an option.

Learning how to prevent postpartum depression and psychosis among these girls is something "gleaned over years of clinical practice," says Dr. Roberto Chaskel, who has treated such girls for nearly 3 decades. "No one tells you how."

At the fourth International Congress of Medicine and Women’s Mental Health, Dr. Chaskel presented video of an 11-year-old who had just given birth days earlier by cesarean section and was experiencing psychosis. The girl had been referred for psychiatric care only after the birth.

Adolescent pregnancies have risen in many Latin American countries in recent decades, despite declining fertility trends overall, according to a 2007 United Nations Report. One Latin American study of 854,377 girls aged 15 years and younger found pregnancy associated with a fourfold higher risk of a host of adverse pregnancy outcomes, including maternal death, early neonatal death, and anemia, compared with women aged 20 years or older (Am. J. Obstet. Gynecol. 2005;192:342-9).

(Meanwhile, the Centers for Disease Control and Prevention reported recently that teenage pregnancy rates in the United States declined 9% from 2009 to 2010, which means that the rate is at an historic low of 34.3 births/1,000 adolescents aged 15-19 years. The decline was seen across all ethnicities.)

In most Latin American countries, including Colombia – where access to abortion is highly restricted, pregnancies among girls aged 15 years and younger often result in birth. Only three Caribbean or Latin American states permit abortion without regard to reason, according to a 2012 report by the Guttmacher Institute. Illegal procedures are estimated to represent 95% of all abortions performed in the region, according to the same report.

In 2006, in Bogotá there were 22,228 pregnancies reported among teenage girls between 10 and 19 years of age (170/100,000), placing Bogotá’s teenage pregnancy rates nearly on nearly on par with those of Uganda and Sierra Leone, according to a 2010 study by researchers at the Universidad Nacional de Colombia. A tenth of the reported pregnancies were to women aged 14 years and younger.

It is possible to prevent psychotic and depressive episodes related to pregnancy and birth and "offer teenagers and adolescents, and the babies of these girls, the best possible quality of life" through a family practice that seeks to mitigate some of the traumas associated with early sex, pregnancy, and birth, and also to guide the early attachment process between mothers and children, said Dr. Chaskel of the department of psychiatry at the Universidad El Bosque and coordinator of child psychiatry at the Fundación Santa Fe, both in Bogotá, Colombia,.

In a separate presentation at the congress, Dr. Marta B. Rondón, a psychiatrist affiliated with the Universidad Peruana Cayetano Heredia in Lima, Peru, discussed the difficulty of achieving an evidence-based understanding of the mental health impact of abortion and unwanted pregnancy in nations where access is restricted and "generally speaking, a woman cannot choose just to terminate a nondesired pregnancy."

In a restricted legal environment, "the condition of secrecy means the woman has to go a very hard road – this could have negative consequences for her mental health – but we don’t have the numbers," Dr. Rondón said, adding that discussing how to conduct research on abortion and mental health in Latin America would be a priority of next year’s international congress on women’s mental health, which will be held in Lima.

Any attempt to get a perspective on the mental health impact of abortion and unwanted pregnancy means using studies conducted in the United States and Europe – different cultural environments that could produce different results. "We need prospective research with randomized samples in Latin America, which may become possible as abortion is gradually decriminalized," Dr. Rondón said.

Currently, Peru and Colombia allow legal abortion only in the event of a threat to the life or physical health of the woman. In addition, Colombia allows terminations in cases of rape or to preserve a woman’s mental health.

Dr. Chaskel said in an interview that the 11-year-old patient in his video would have been a candidate for legal abortion under Colombian law and that he would have referred her had she presented to him early. However, he said, her obstetrician had judged her ineligible.

Their options might be limited in terms of a choice to terminate, but pregnant adolescents in Latin America do have the benefit of strong family ties, and Dr. Chaskel’s practice taps into the high level of familial support available to most. "You bring grandma and grandpa, and the new uncles and aunts into clinical practice – right into the office," he said in an interview. A pregnancy in adolescence "generates confusion not only for the girl but also on the whole family group: In Latin America, this usually means three generations confused as to how to approach this situation."

The initial goal of the interventions, he said, is to help pregnant adolescents avoid postpartum depression and psychosis. The longer-term goal is to allow them to continue in their adolescence as normally as possible after the birth, while developing a healthy attachment to the child with the support of their families.

"Are they going to keep listening to Lady Gaga? If you have an 18-month-old baby, how do you behave? We’ve really worked on recuperating adolescence for these girls to make sure that they do listen to Lady Gaga," he said. "We try to make sure that if they’re going to have the baby, to know what they want to do – go back to school, go to a friend’s 15th birthday party [Quinceañera], or have one themselves.

"We think it over together."

After the birth, infants and their young mothers are observed and evaluated interacting in-office, where such details as the distance the child crawls away from the mother is measured as a way of gauging healthy attachments. The girls, who are at high risk of having second babies while still in their teenage years, need to be followed up for years.

Neither Dr. Chaskel nor Dr. Rondón reported disclosures.

MEDELLIN, Columbia – After years of debate and controversy, premenstrual dysphoric disorder could be closer to getting recognized as a full category of mood disorder in the DSM-5, a leading researcher in women’s mental health predicts.

Dr. Meir Steiner, who served as an adviser to the DSM-5’s Mood Disorders Work Group dealing with PMDD, sees the possible repositioning of PMDD within the revised manual as something of a triumph.

The new criteria for PMDD, a severe variant of premenstrual syndrome estimated to affect up to 5% of premenopausal women (Am. J. Psychiatry 2012;AiA:1-11), differ somewhat from those described in the DSM-IV. The order of symptoms likely will be shuffled, with mood swings and irritability now at the top of the list, where "markedly depressed mood" had topped the DSM-IV’s, Dr. Steiner said at the International Congress of Medicine and Women’s Mental Health.

PMDD first appeared as "late luteal phase dysphoric disorder" in Appendix A of the DSM-III-R in 1987, over the objections of some women’s groups and clinicians, who viewed its inclusion as pathologizing the menstrual cycle. The name of the disorder was changed to PMDD for the DSM-IV. Debate over PMDD intensified in 2000, when the Food and Drug Administration approved the rebranding of the selective serotonin reuptake inhibitor (SSRI) fluoxetine under the marketing name Sarafem to treat PMDD. Critics saw in the new indication an example of "disease mongering" benefiting pharmaceutical manufacturers (PLoS Med. 2006;3:e198).

Proponents of PMDD such as Dr. Steiner counter that the menstrual fluctuations in physical and emotional symptoms most women experience would not be considered pathological under the DSM-IV or DSM-5 diagnostic criteria, which require that 5 or more of 11 listed symptoms occur in most menstrual cycles during the luteal phase, begin to improve within a few days after the onset of menses, and are minimal or absent in the week post menses.

Moreover, they say, the criteria can prevent affected women from being incorrectly diagnosed with a depressive or personality disorder.

In the past decade, the debate on PMDD has calmed considerably, thanks in part to evidence from randomized controlled trials using the DSM-IV criteria for PMDD. The European Medicines Agency, which long refused to validate the indication, changed its position in 2010, opening up the possibility for PMDD treatments to be tested and marketed in the European Union.

Research has shown that PMDD can be treated with oral contraceptives containing drospirenone and ovarian suppression with GnRH agonists. It can also be treated with a wide range of SSRIs, which a meta-analysis of 29 randomized controlled trials involving a total of 2,964 patients showed to be effective in alleviating the mood and physical symptoms associated with PMDD (Obstet. Gynecol. 2008;111:1175-82). Unlike in depression, "you can actually accomplish improvement with a few days of treatment" with SSRIs, allowing for intermittent treatment, said Dr. Steiner. He served on an advisory body for the DSM-IV, where PMDD is not listed as a diagnostic category but in an appendix of criteria warranting further study.

In a separate talk at the congress, Dr. Steiner described other women-specific changes that he hopes to see in the DSM-5. He said the DSM-5 should include a category for childbirth-related posttraumatic stress disorder, in which the act of birthing is the triggering trauma.

"There is also no specific category for perinatal bereavement. This should be corrected," said Dr. Steiner, professor emeritus in the departments of psychiatry and behavioural neurosciences and obstetrics and gynecology at McMaster University in Hamilton, Ont.

Additionally, Dr. Steiner said that he would like to see changes to the diagnostic criteria for postpartum depression, and that the DSM-5 should extend the diagnostic window for its onset to 6 months post partum. And finally, he said, the DSM-5 also should identify depression onset during perimenopause as something distinct from depression in other periods of life. "We would like to identify perimenopause as a new window of vulnerability and risk," he said.

Despite his optimism about PMDD and the DSM-5, Dr. Steiner remained critical of the diagnostic manual as a whole, describing the DSM-IV as a "failure" for women. "Right now we’re looking at how we can prevent another failure," he said.

Dr. Steiner disclosed recent financial support from several pharmaceutical companies, including AstraZeneca, Azevan, Bayer Canada, and Servier.

MEDELLIN, Columbia – After years of debate and controversy, premenstrual dysphoric disorder could be closer to getting recognized as a full category of mood disorder in the DSM-5, a leading researcher in women’s mental health predicts.

Dr. Meir Steiner, who served as an adviser to the DSM-5’s Mood Disorders Work Group dealing with PMDD, sees the possible repositioning of PMDD within the revised manual as something of a triumph.

The new criteria for PMDD, a severe variant of premenstrual syndrome estimated to affect up to 5% of premenopausal women (Am. J. Psychiatry 2012;AiA:1-11), differ somewhat from those described in the DSM-IV. The order of symptoms likely will be shuffled, with mood swings and irritability now at the top of the list, where "markedly depressed mood" had topped the DSM-IV’s, Dr. Steiner said at the International Congress of Medicine and Women’s Mental Health.

PMDD first appeared as "late luteal phase dysphoric disorder" in Appendix A of the DSM-III-R in 1987, over the objections of some women’s groups and clinicians, who viewed its inclusion as pathologizing the menstrual cycle. The name of the disorder was changed to PMDD for the DSM-IV. Debate over PMDD intensified in 2000, when the Food and Drug Administration approved the rebranding of the selective serotonin reuptake inhibitor (SSRI) fluoxetine under the marketing name Sarafem to treat PMDD. Critics saw in the new indication an example of "disease mongering" benefiting pharmaceutical manufacturers (PLoS Med. 2006;3:e198).

Proponents of PMDD such as Dr. Steiner counter that the menstrual fluctuations in physical and emotional symptoms most women experience would not be considered pathological under the DSM-IV or DSM-5 diagnostic criteria, which require that 5 or more of 11 listed symptoms occur in most menstrual cycles during the luteal phase, begin to improve within a few days after the onset of menses, and are minimal or absent in the week post menses.

Moreover, they say, the criteria can prevent affected women from being incorrectly diagnosed with a depressive or personality disorder.

In the past decade, the debate on PMDD has calmed considerably, thanks in part to evidence from randomized controlled trials using the DSM-IV criteria for PMDD. The European Medicines Agency, which long refused to validate the indication, changed its position in 2010, opening up the possibility for PMDD treatments to be tested and marketed in the European Union.

Research has shown that PMDD can be treated with oral contraceptives containing drospirenone and ovarian suppression with GnRH agonists. It can also be treated with a wide range of SSRIs, which a meta-analysis of 29 randomized controlled trials involving a total of 2,964 patients showed to be effective in alleviating the mood and physical symptoms associated with PMDD (Obstet. Gynecol. 2008;111:1175-82). Unlike in depression, "you can actually accomplish improvement with a few days of treatment" with SSRIs, allowing for intermittent treatment, said Dr. Steiner. He served on an advisory body for the DSM-IV, where PMDD is not listed as a diagnostic category but in an appendix of criteria warranting further study.

In a separate talk at the congress, Dr. Steiner described other women-specific changes that he hopes to see in the DSM-5. He said the DSM-5 should include a category for childbirth-related posttraumatic stress disorder, in which the act of birthing is the triggering trauma.

"There is also no specific category for perinatal bereavement. This should be corrected," said Dr. Steiner, professor emeritus in the departments of psychiatry and behavioural neurosciences and obstetrics and gynecology at McMaster University in Hamilton, Ont.

Additionally, Dr. Steiner said that he would like to see changes to the diagnostic criteria for postpartum depression, and that the DSM-5 should extend the diagnostic window for its onset to 6 months post partum. And finally, he said, the DSM-5 also should identify depression onset during perimenopause as something distinct from depression in other periods of life. "We would like to identify perimenopause as a new window of vulnerability and risk," he said.

Despite his optimism about PMDD and the DSM-5, Dr. Steiner remained critical of the diagnostic manual as a whole, describing the DSM-IV as a "failure" for women. "Right now we’re looking at how we can prevent another failure," he said.

Dr. Steiner disclosed recent financial support from several pharmaceutical companies, including AstraZeneca, Azevan, Bayer Canada, and Servier.

MEDELLIN, Columbia – After years of debate and controversy, premenstrual dysphoric disorder could be closer to getting recognized as a full category of mood disorder in the DSM-5, a leading researcher in women’s mental health predicts.

Dr. Meir Steiner, who served as an adviser to the DSM-5’s Mood Disorders Work Group dealing with PMDD, sees the possible repositioning of PMDD within the revised manual as something of a triumph.

The new criteria for PMDD, a severe variant of premenstrual syndrome estimated to affect up to 5% of premenopausal women (Am. J. Psychiatry 2012;AiA:1-11), differ somewhat from those described in the DSM-IV. The order of symptoms likely will be shuffled, with mood swings and irritability now at the top of the list, where "markedly depressed mood" had topped the DSM-IV’s, Dr. Steiner said at the International Congress of Medicine and Women’s Mental Health.

PMDD first appeared as "late luteal phase dysphoric disorder" in Appendix A of the DSM-III-R in 1987, over the objections of some women’s groups and clinicians, who viewed its inclusion as pathologizing the menstrual cycle. The name of the disorder was changed to PMDD for the DSM-IV. Debate over PMDD intensified in 2000, when the Food and Drug Administration approved the rebranding of the selective serotonin reuptake inhibitor (SSRI) fluoxetine under the marketing name Sarafem to treat PMDD. Critics saw in the new indication an example of "disease mongering" benefiting pharmaceutical manufacturers (PLoS Med. 2006;3:e198).

Proponents of PMDD such as Dr. Steiner counter that the menstrual fluctuations in physical and emotional symptoms most women experience would not be considered pathological under the DSM-IV or DSM-5 diagnostic criteria, which require that 5 or more of 11 listed symptoms occur in most menstrual cycles during the luteal phase, begin to improve within a few days after the onset of menses, and are minimal or absent in the week post menses.

Moreover, they say, the criteria can prevent affected women from being incorrectly diagnosed with a depressive or personality disorder.

In the past decade, the debate on PMDD has calmed considerably, thanks in part to evidence from randomized controlled trials using the DSM-IV criteria for PMDD. The European Medicines Agency, which long refused to validate the indication, changed its position in 2010, opening up the possibility for PMDD treatments to be tested and marketed in the European Union.

Research has shown that PMDD can be treated with oral contraceptives containing drospirenone and ovarian suppression with GnRH agonists. It can also be treated with a wide range of SSRIs, which a meta-analysis of 29 randomized controlled trials involving a total of 2,964 patients showed to be effective in alleviating the mood and physical symptoms associated with PMDD (Obstet. Gynecol. 2008;111:1175-82). Unlike in depression, "you can actually accomplish improvement with a few days of treatment" with SSRIs, allowing for intermittent treatment, said Dr. Steiner. He served on an advisory body for the DSM-IV, where PMDD is not listed as a diagnostic category but in an appendix of criteria warranting further study.

In a separate talk at the congress, Dr. Steiner described other women-specific changes that he hopes to see in the DSM-5. He said the DSM-5 should include a category for childbirth-related posttraumatic stress disorder, in which the act of birthing is the triggering trauma.

"There is also no specific category for perinatal bereavement. This should be corrected," said Dr. Steiner, professor emeritus in the departments of psychiatry and behavioural neurosciences and obstetrics and gynecology at McMaster University in Hamilton, Ont.

Additionally, Dr. Steiner said that he would like to see changes to the diagnostic criteria for postpartum depression, and that the DSM-5 should extend the diagnostic window for its onset to 6 months post partum. And finally, he said, the DSM-5 also should identify depression onset during perimenopause as something distinct from depression in other periods of life. "We would like to identify perimenopause as a new window of vulnerability and risk," he said.

Despite his optimism about PMDD and the DSM-5, Dr. Steiner remained critical of the diagnostic manual as a whole, describing the DSM-IV as a "failure" for women. "Right now we’re looking at how we can prevent another failure," he said.

Dr. Steiner disclosed recent financial support from several pharmaceutical companies, including AstraZeneca, Azevan, Bayer Canada, and Servier.