Sarafem Nation

Renamed Prozac Targets Huge Market: Premenstrual Women

A visibly irritated woman yanks on a supermarket shopping cart that's stuck in its stack while a soothing female voice-over recites a litany of PMS symptoms. She asks, "Think it's PMS? Think again. . . . It could be PMDD."

Premenstrual Dysphoric Disorder, or PMDD, is a fresh-minted mental illness that purportedly affects 3 to 10 percent of all menstruating women. Mood symptoms like depression, anxiety, anger, irritability, or sensitivity to rejection are said to be so severe the week before a woman's period that it impairs her functioning. According to Dr. Jean Endicott, professor of clinical psychology at Columbia University's College of Physicians and Surgeons, "What's ordinarily irritating becomes enraging."

To be diagnosed with PMDD, women must keep a daily diary of their symptoms for the duration of two menstrual cycles. The symptoms must kick in after ovulation and disappear once menstruation begins. "The timing is exquisite," remarks Endicott.

illustration: Jonathan Weiner

The timing is also exquisite for Eli Lilly and Company to make a financial killing off of PMDD. Next year, the drug company will lose its patents on the antidepressant Prozac, and with them its monopoly on the market. To ward off declining profits, Lilly has found another use for its wonder drug—treating PMDD.

In July, Lilly got Food and Drug Administration approval to market Prozac under the new name Sarafem. The company is packaging the drug in pretty pink and lavender capsules, exclusively for women, most in their late twenties or early thirties. Says Laura Miller, a spokesperson for Lilly, "Women told us they wanted treatment that would differentiate PMDD from depression."

According to Endicott, the symptoms of PMDD primarily interrupt "interpersonal relationships"—basically, those involving spouses, children, and coworkers. In one group of women with self-described premenstrual symptoms, researchers found no increase in absenteeism or decline in work performance, although the women themselves perceived that to be the case.

"PMDD is unique because there is virtually no other disease that people insist upon having," says Dr. Nada Stotland, chair of psychiatry at Illinois Masonic Medical Center. According to Stotland, the majority of women who go to PMS clinics have symptoms that aren't in fact related to their periods. "Most are depressed everyday. Others have anxiety and personality disorders. Some are in psychological pain because they are being abused."

That women might seek help on the pretense their problems are hormonally based makes PMDD more slippery to recognize and study. Stotland says she's particularly concerned that Lilly is targeting almost exclusively OB-GYNs as Sarafem prescribers, which puts gynecologists in the position of treating mental illness. She says Lilly's advertising campaign may convince enough women they need Sarafem, leading them to pressure their doctors to skip the two months needed for diagnosis and instead send them straight to the pharmacy. And since Sarafem will also work for those with chronic depression, a misdiagnosis can go undetected.

Proponents of Sarafem downplay the potential for misuse. "I doubt that a lot of people who don't need the treatment would get it," argues Endicott. "First, it's a prescription drug. Second, women are not big pill poppers." Sherry Marts, scientific director of the Society for Women's Health Research—a nonprofit organization that promotes research in women's health issues—concurs. "This is a real medical condition that requires treatment for a small percentage of women," she says."Not, 'I'm a little bloated, I'm gonna pop some Prozac.' "

But critics claim that 3 to 10 percent of all menstruating women is no small number. "That's a minimum of half a million North American women suffering from PMDD," says Paula Caplan, a psychologist and affiliated scholar at Brown University's Pembroke Center for Research and Teaching on Women.

Whether PMDD is a real condition is still subject to debate. Although both sides agree that a certain subset of women may be sensitive to normal hormonal changes, that's about all they agree on. The question remains, if women sometimes snap at their husbands if they don't pick up after themselves, or at their kids if they do poorly in school, should they be branded with a mental disorder? "Women are commonly in situations defined by stress—responsibility without authority," says Stotland. 'That's almost the definition of a typical woman's job."

Some doctors fear that women who have legitimate reasons to be unhappy will be silenced by the PMDD diagnosis, and that Sarafem could prove to be the Valium of the naughts. "Ordinary, healthy changes in mood and emotion are being pathologized when they happen to women, and since women believe they shouldn't feel irritable, angry, or depressed, they are quick to blame themselves," says Caplan. For men, "There's no testosterone-based aggressive disorder."

Endicott disagrees. "If men had PMDD, it would have been studied a long time ago."

But would it? "To say that a huge proportion of the female population is disabled represents a potentially horrendous setback for women in the workplace," says Stotland. She points to the woman who finally speaks up to her boss and in return is asked, "Oh, is it that time of the month?" Agreeing to that kind of put-down might save the woman her job. PMDD could reinforce the stereotype of the hysterical woman not only to employers, but to women themselves.

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