Does suicidal thinking and self-harm follow the menstrual cycle in PMDD?

Background: Suicide rates among reproductive-aged females have increased in recent decades, yet biopsychosocial contributors to risk remain understudied. Evidence suggests mood and behavior changes across the menstrual cycle, most notably in premenstrual disorders (PMDs), are associated with elevated suicide and self-harm risk. However, research on suicidality across the menstrual cycle remains limited due to a lack of prospective studies targeting PMD samples. Methods: Participants completed prospective daily ratings of PMD, suicidal, and self-harm symptoms across two menstrual cycles. PMD diagnosis was confirmed with these ratings, and phase-aligned cycle time scaling was used to align observations continuously across the cycle. Generalized additive mixed models tested the cyclicity of suicidal and self-harm ideation, and, as secondary analyses, likelihood ratio tests evaluated PMD diagnosis (above vs. below diagnostic threshold) as a moderator of cyclic variation as well as additional psychosocial factors that may affect cyclical patterns. Results: Significant menstrual cyclicity in suicidal (deviance explained = 38%) and self-harm (deviance explained = 21.6%) ideation was observed in the full sample, with severity peaking in the late luteal phase, improving by menses onset, and re-emerging around ovulation. When comparing groups above vs. below diagnostic threshold for PMD, cyclicity was only significant in participants above threshold (n = 35); individuals below threshold (n = 29) showed cyclicity that was statistically nonsignificant. Within those above diagnostic threshold, various psychosocial factors shaped the cyclicity of suicidality and self-harm, including psychiatric comorbidities, social support, childhood adversities, life stressors, baseline suicidal risk, and mid-follicular depressive symptoms. Conclusion: Cyclic worsening of suicidality and self-harm are evident among individuals being evaluated for PMDs and may be exacerbated by psychosocial vulnerabilities. Prospective, continuous symptom tracking enables identifying high-risk periods and informing targeted prevention strategies.

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