What medications do you consider for patients with premenstrual dysphoric disorder who do not respond to SSRIs?

In addition to emphasizing how helpful self-care can be (a little more sleep than usual, exercise, healthy nutrition, including limiting carbs, mindfulness), calcium carbonate 600 mg BID, judicious benzodiazepines, and gabapentin 100-300 mg hs can be helpful. Continuous OCPs can also be very useful. For extreme cases, significantly more aggressive strategies, likely GnRH antagonists or oophorectomy, can also be considered. It is also really important to treat any comorbid disorders and symptoms that aren't limited to the late luteal phase. For all women with concerns about PMDD, the standard recommendation is tracking periods and symptoms for at least 3 months. For mild symptoms or PMDD, sometimes tracking and just naming the symptoms and r...

Tracking symptoms for several months is important to establish that the problem is indeed premenstrual dysphoric disorder, rather than the periodic exacerbation of a more persistent depressive disorder, borderline personality disorder with mood swings that sometimes coincide with menses, or a form of bipolar II disorder. Some women with PMDD also have intermittently disabling cognitive symptoms that can lead to anxiety and feelings of failure.

Each of these disorders may require a different approach, ranging from consistent rather than intermittent treatment with any antidepressant (possibly with dose increases during the premenstrual week), trauma-informed care, and possibly use of lithium or an anticonvulsant (ideally not Depakote) if ra...