Re: An Interesting Presentation About Cyclical Menstrual Psychosis with an Updated Review of Literature

We read with great interest the article by S. Thippaiah and colleagues in a recent issue of the journal.1 The authors reported the interesting case of a 19-year-old woman who presented with cyclical changes in mood and behavior, alternating between depression and mania, and a correlation with her menstrual cycle was made. Despite the fact that the menstrual psychoses have been described for two centuries, the knowledge and familiarity about the disorder remain poor, leading to inaccurate diagnoses and suboptimal treatment and prognosis. The authors should be congratulated for identifying this correlation of the patient’s symptoms and her hormonal cycles and raising awareness for such an important entity that often goes undetected. Although the case report is absolutely relevant and informative, there is a crucial point that we would like to address, i.e., the choice of valproic acid as the mood stabilizer for a 19-year old woman. In women of reproductive age, valproic acid should perhaps be among the last options to be considered given its teratogenic potential and neurocognitive effects in the developing fetus. When alternative drugs are not an option, the clinician must extensively review and discuss the risks with the patient and concurrently offer contraception and start her on 4 mg of folic acid to reduce those risks.2 Careful documentation about that discussion, with an individual risk/benefit analysis, should be made.