mation of the corpus luteum, which is essential for the symptoms of PMS. Dietary modification with high- carbohydrate diet, calcium supplementation, 6 and de- creased caffeine could be helpful in preventing PMS. Depending on the type of PMS the patient has, appro- priate therapy could be initiated. The use of selective serotonin reuptake inhibitors (SSRIs) has been investigated in PMS treatmentJ-ll Tiemstra did not mention periodic and continuous therapy as an option. In our practice we find that PMS with aura can often be treated with a periodic use of SSRI about 10 days before the menstrual period or dur- ing the luteal phase. Patients with no aura can be cycled on the SSRI to coincide with the luteal phase. Continu- ous use of SSRI is warranted if depressive symptoms persist 4 days after onset of menstrual bleeding. The patient can derive most benefit from appropri- ate use of diagnostic skills combined with individual- ized therapy. References Niharika Khanna, MD University of Maryland School of Medicine Baltimore 1. Tiemstra ]D, Patel K. Honnonal therapy in the management of premenstrual syndrome.] Am Board F am Pract 1998; 11 : 378-81. 2. Schmidt P], Nieman LK, Danaceau MA, Adams LF, Rubi- now DR. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. N Engl] Med 1998;338:209-16. 3. FitzGerald M, Malone KM, Li S, Harrison WM, McBride PA, Endicott], et al. Blunted serotonin response to fen flu- ramine challenge in premenstrual dysphoric disorder. Am] Psychiatty 1997;154:556-8. 4. Halbreich U. Menstrually related disorders - towards inter- disciplinary international diagnostic criteria. Cephalalgia 1997; 17(Suppl 20):1-4. 5. Singh BB, Berman BM, Simpson RL, Annechild A. Inci- dence of premenstrual syndrome and remedy usage: a na- tional probability sample study. Altern Ther Health Med 1998;4(3):75-9. 6. Thys-]acobs S, Starkey P, Bernstein D, TianJ. Calcium car- bonate and the premenstrual syndrome: effects on premen- strual and menstrual symptoms. Premenstrual Syndrome Study Group. Am] Obstet GynecoI1998;179:444-52. 7. Yonkers KA. Antidepressants in the treatment of premen- strual dysphoric disorder.] Clin Psychiatry 1997;58(Suppl 14):4-10, discussion 11-3. 8. Steiner M, Korzekwa M, Lamont], WIlkins A. Intennittent fluoxetine dosing in the treatment of women with premen- strual dysphoria. Psychophannacol Bull 1997;33:771-4. 9. Halbreich U, Smoller JW Intennittent luteal phase sertraline treatment of dysphoric premenstrual syndrome.] Clin Psy- chiatty 1997;58:399-402. 10. Yonkers KA, Halbreich U, Freeman E, Brown C, Endicott], Frank E, et al. Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. A randomized controlled trial. Sertraline Premenstrual Dysphoric Collabo- rative Study Group.]AMA 1997;278:983-8. 182 JABFP March-Aprill999 Vol. 12 No.2 11. Young SA, Hurt PH, Benedek DM, Howard RS. Treatment of premenstrual dysphoric disorder with sertraline during the luteal phase: a randomized, double-blind, placebo-controlled crossover trial.] Clin Psychiatry 1998;59:76-80. Reimbursement for Flexible Sigmoidoscopy To the Editor: I am a family physician currently in prac- tice in northeast Maryland. I enjoyed Dr. Rodney's edi- torial exploring the possible reasons why flexible sig- moidoscopy has not received widespread acceptance among physicians in general and family physicians in particular (Rodney"WM. WIll virtual reality simulators end the credentialing arms race in gastrointestinal en- doscopy or the need for family physician faculty with endoscopic skills? J Am Board Fam Pract 1998;11:492- 5). His reasoning is good, but he misses the major rea- son why we don't routinely perform the procedure- lack of reimbursement. These sigmoidoscopes are not inexpensive, and most insurers are unwilling to provide more than a pittance for performing a procedure that will take 45 minutes, including setup and cleaning. I do not own a sigmoidoscope; in the past I used the hospital equipment. I have since stopped, as managed care com- panies would rather I refer the patient to a gastroen- terologist who does own the sigmoidoscope, thus avoid- ing a room charge at the hospital. In the time it would take me to perform the procedure, I can see 4 to 6 pa- tients. I am not adverse to doing procedures; I perform skin biopsies and vasectomies in my office, and I have an active intensive care practice in the hospital. At a recent managed care workshop it was noted that the behavior you reward is the behavior you get. Offer- ing flexible sigmoidoscopy, as currently reimbursed, is a losing proposition and a poor business decision. I refer my patients to another physician for this procedure, at least those I can convince to pursue the test. John R. Mulvey, MD Elkton,Md Role of Balint Groups in Caring for Patients With Unexplained Symptoms To the Editor: We wish to comment on "Understanding and Caring for the Distressed Patient With Multiple Medically Unexplained Symptoms" by Walker et aU We agree with many of the concepts presented in the paper, and the way in which the P-P-P model is devel- oped and related to clinical practice is excellent. Nev- ertheless, we find it unfortunate that the reference to the work of Michael Balint is limited to mentioning Balint groups as "an example of physician support groups." Through his work with general practitioners in the United Kingdom, Michael Balint pioneered the investi- gation of how primary care providers effectively deal with patients who complain of unexplained somatic symptoms. Although based on observations gathered with physicians 40 years ago, Balint's seminal work The Doctor, His Patient and the IlinesSl introduces concepts that are echoed by Walker et al. These include the complex interaction between psychosocial factors and on 14 June 2020 by guest. Protected by copyright. http://www.jabfm.org/ J Am Board Fam Pract: first published as 10.3122/jabfm.12.2.182b on 1 March 1999. Downloaded from