Abstract

BACKGROUND

The impact of metabolic and reproductive features of polycystic ovary syndrome (PCOS) compromises psychological functioning. We investigated factors associated with negative psychological functioning to determine whether they were predictive of anxiety and depression in PCOS.

METHODS

A cross-sectional study was performed by questionnaire in 177 women with PCOS (mean ± SD age 32.8 ± 7.8 years) and 109 healthy controls (mean age 41.9 ± 15.4 years). Main outcome measures were anxiety and depression, measured using the Hospital Anxiety Depression Scale (HADS) and Multidimensional Body-Self Relations Questionnaire (MBSRQ), respectively.

RESULTS

Women with PCOS, compared with control women, had a higher mean anxiety HADS score (9.5 ± 3.9 versus 6.5 ± 3.6; P < 0.001), a higher mean depression score (5.7 ± 3.7 versus 3.3 ± 3.1; P < 0.001) and more negative body image in 7 out of 10 subscales of the MBSRQ. Multivariate regression analysis in PCOS showed that anxiety was predicted by self-worth (P < 0.0001), health evaluation (P = 0.005), time taken to diagnose PCOS (P = 0.003) and age (P = 0.02), while in control women, anxiety was predicted by self-worth (P = 0.009), health evaluation (P = 0.001) and rural living (P = 0.03). Depression in PCOS was predicted by self-worth (P = 0.0004), quality of life (QOL) (P = 0.004), fitness orientation (P = 0.002), appearance evaluation (P = 0.001) and time to diagnosis (P = 0.03) and in women without PCOS, by self-worth (P < 0.0001), QOL (P < 0.0001), illness orientation (P = 0.001) and appearance orientation (P = 0.02).

CONCLUSIONS

Women with PCOS have increased anxiety, depression and negative body image compared with women without PCOS. In women with or without PCOS, body image and self-worth are predictors of both anxiety and depression, while QOL also predicts only depression. Time taken to diagnose PCOS is associated with poor psychological functioning.

Introduction

Polycystic ovary syndrome (PCOS), a reproductive endocrine disorder, affects 12–18% of the female population (diagnosed using Rotterdam criteria) (March et al., 2010). The associated metabolic and reproductive features of PCOS, such as acne, hirsutism and menstrual irregularity as well as the increased prevalence of obesity and infertility, adversely impact on psychological functioning and quality of life (QOL) (Jones et al., 2008a). Chronic disease is also a known risk factor for depression (Lustman et al., 2000; Gold et al., 2002; Wilhelm et al., 2003; Brydon et al., 2006), although less is understood about the interplay of chronic disease and anxiety (Roy-Byrne et al., 2008). Although there is some recognition that women with PCOS experience higher rates of depression and anxiety than women in the general population (Mansson et al., 2008; Jedel et al., 2010), the research literature exploring contributory factors is inconclusive and inconsistent. This gap in knowledge is of concern, given the high prevalence of PCOS and the physical and psychological burden the disease appears to place on women.

The prevalence of depression in women with PCOS is higher and more variable (28–64%) (Bhattacharya and Jha, 2010; Laggari et al., 2009; Deeks et al., 2010) than for women in the general population (7.1–8%) (ABS, 2007; Gwynn et al., 2008). The prevalence of anxiety in women with PCOS ranges from 34 (Deeks et al., 2010) to 57% (Benson et al., 2009a,b), yet again a higher prevalence than for women in the general population (18%) (ABS, 2007). In particular, women with PCOS have been found to be at an increased risk of social phobia and suicide attempts (Mansson et al., 2008).

The reasons for a higher prevalence of anxiety and depression in women with PCOS are likely to be complex. Some reviewers (Eggers and Kirchengast, 2001; Bishop et al., 2009) suggest that physical symptoms experienced by women with PCOS are the likely cause of psychological distress; however, the evidence is inconsistent in relation to which specific factors. While acne (Benson et al., 2009a,b), hirsutism and BMI (Hahn et al., 2005) have been linked to increased psychological distress in some studies, no link is demonstrated in others (Kerchner et al., 2009). Further, women having difficulties with fertility were more likely to be depressed in some studies (Benson et al., 2009a,b; Deeks et al., 2010), while other studies have not found this link (Hahn et al., 2005; Kerchner et al., 2009). Insulin resistance has also been inconsistently associated with higher depression (Rasgon et al., 2003; Hahn et al., 2005). It is likely that multiple factors contribute to the high prevalence of both anxiety and depression in women with PCOS.

Any examination of psychological function in women with PCOS should also explore other known influencing factors. The complex nature of PCOS and the frustrations of being diagnosed with such a disease are likely to cause psychological distress in some women (Kitzinger and Willmott, 2002; Avery and Braunack-Mayer, 2007). Studies using both the PCOS QOL scale (PCOSQ) and scales such as the short form 36 (SF-36) health survey questionnaire have found that health-related (HRQoL) and overall QOL are compromised in women with PCOS (Coffey et al., 2006; Barnard et al., 2007; Ching et al., 2007). More specifically, studies that used the PCOSQ reported that weight gain appeared to have the greatest influence on HRQoL, whereas research using the SF-36 pointed to poorer psychological HRQoL (Jones et al., 2008a). A small improvement in HRQoL has been observed using treatment such as metformin and lifestyle modification (Hahn et al., 2006; Harris-Glocker et al., 2009); however, further research is needed. Interestingly, negative body image was strongly associated with depression in a study by Himelein and Thatcher (2006) and in a small sample (n = 23), body image distress was highly prevalent in women with PCOS (Liao et al., 2008). Unfortunately, very little comprehensive exploration of body image in women with PCOS has been conducted to understand this link further. Research in populations other than those with PCOS have consistently found that factors such as self-worth and self-esteem (Lin et al., 2008; Orth et al., 2009), relationship and family status (Runkewitz et al., 2006; Weinberger et al., 2008), social support (Yang et al., 2009) and household income (Beard et al., 2008; Nandi et al., 2009) all likely impact on psychological function and these also require a thorough investigation in women with PCOS.

It is difficult to draw any conclusions about prevalence and factors contributing to anxiety and depression in women with PCOS owing to limitations in the research methodology and design of previous studies. Studies of psychological distress in women with PCOS are limited by small sample sizes (Rasgon et al., 2003; Liao et al., 2008; Laggari et al., 2009; Rofey et al., 2009), lack of inclusion of control groups (Rasgon et al., 2003, 2005; Sundararaman et al., 2008; Benson et al., 2009a,b; Thomson et al., 2010) and reliance on clinic samples (O'Donovan et al., 2002; Mansson et al., 2008; Sundararaman et al., 2008; Laggari et al., 2009; Thomson et al., 2010). Further understanding of this area is needed.

The aim of the present study was to provide a broader-based understanding of depression and anxiety using a large, community-based, representative sample of women with PCOS compared with controls, without PCOS. We aimed to examine whether PCOS status independently predicts prevalence of anxiety and depression, and second to examine a range of predictors for anxiety and depression including those relevant to the PCOS experience, such as BMI, infertility, body image, time to a diagnosis and QOL, and also more general predictors, such as interpersonal support, socioeconomic status and self-worth.

Materials and Methods

Participants

This study was approved by the Southern Health Human Research Ethics Committee C (Project No. 07070C). All assessments were undertaken with the understanding and informed consent of each participant. A cross-sectional study of Australian women with (n = 248) and without (n = 126) PCOS was conducted using comprehensive surveys, either mailed or online. Women were recruited throughout rural and metropolitan Australia. Consistently worded advertisements stating 'We are very interested in what you think and feel about your health' were used across a range of community settings, including a general women's health website (http://www.jeanhailes.org.au), a support group website for women with PCOS (women were not necessarily members of the support group, simply website visitors), medical clinics, newsletters, magazines and newspapers. Women were required to reside in Australia, be aged 18–70 years, and be able to read and write in English. PCOS status was based on a prior-established medical diagnosis, confirmation at phone screening and medical questions on PCOS features included in the survey. The in-depth phone screening was completed by an experienced researcher in PCOS (author M.G.H.) using diagnostic features based on the Rotterdam criteria (Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group, 2004), with at least two of the following: polycystic ovaries on ultrasound, high androgen levels/clinical hyperandrogenism and menstrual irregularity. Queries or discrepancies between prior medical diagnoses, phone screening and survey responses were clarified in conjunction with an experienced clinical endocrinologist (author H.J.T.). To reduce confounding effects, women were excluded whether pregnant or had been diagnosed with heart disease or a psychiatric illness other than depression or anxiety.

Tools

Both validated and devised measures on health-related behaviour, symptoms experienced, mood, QOL, self-worth, body image and diagnosis experience were administered. One of the tools used included a general questionnaire devised by the authors, and refined with input from key stakeholders. General themes of the proposed study as well as specific validated and newly devised tools were presented and feedback sought from a consumer focus group (n = 42) and an advisory group (two gynaecologists, three endocrinologists, two education project managers, one psychologist, one research assistant, one dietician and two general practitioners). Women with PCOS then filled out an initial survey and provided further feedback to form a draft survey tool, which was used in a pilot study of 51 women with PCOS. Results from the pilot were used to further refine the final survey tool used in the current study (Deeks et al., 2010).

The devised questionnaire included detailed demographics and clinical PCOS features. QOL was investigated with the question ‘How would you rate your overall QOL over the past year’ using a five-point Likert scale (poor = 1, excellent = 5). Self-worth was evaluated using the statement ‘I am a worthwhile person, at least on an equal plane with others’ (strongly disagree = 1, strongly agree = 5). Time to diagnosis was self-reported and defined as the duration between first seeing a health professional about symptoms and the time of PCOS diagnosis (four-point Likert scale 1 = within 6 months, 4 = greater than 2 years). Self-reported height and weight were used to calculate BMI. Clinical levels of anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS) (Zigmond and Snaith, 1983), a validated, standardized questionnaire using four-point Likert scales. The 14 items in the HADS (7 for anxiety and 7 for depression) are given a score from 0 to 3 with a total score for either depression or anxiety ranging from 0 to 21. A score of 8 or above is considered to mean that anxiety and/or depression is present. Body image was investigated using the Multidimensional Body-Self Relations Questionnaire (MBSRQ), a validated, 69 item questionnaire employing five-point Likert scales (one definitely disagree to five definitely agree) and divided into 10 subscales including ‘Evaluation’ of how one thinks and feels about (i) appearance, (ii) fitness and (iii) health. Further subscales assess ‘Orientation’ which refers to the importance of (iv) appearance, (v) fitness, (vi) health and (vii) illness to a person. Finally, other subscales assess (viii) overweight preoccupation (ix) self-classified weight and the (x) Body Areas Satisfaction Scale (Cash, 1994). Scoring of the MBSRQ involves applying the formulae relevant to each subscale (some items are reverse-scored and require application of a constant), and then mean subscale scores are calculated.

Statistics

All analysis was performed using SAS version 9.1 (SAS Institute Inc., Cary, NC, USA). The outcome measures of anxiety and depression were assessed for normality and found to be well approximated by a normal distribution. A comparison between women with and without PCOS was performed using Student's t-test, χ2 test for equal proportions or non-parametric tests, as appropriate. Univariate and multivariate analysis for anxiety and depression were determined using linear and multiple linear regressions. To account for differences in age and BMI between women with and without PCOS, these factors were included in all multivariate models. Results from linear regression analyses were reported as parameter estimates (PEs) with SE. A two-sided P-value of 0.05 was considered statistically significant. Continuous data were reported as mean ± SD, and categorical data as proportions.

Sample size

Previous studies have reported a difference of at least 20% in the prevalence of depression and anxiety between women with or without PCOS (ABS, 2007; Gwynn et al., 2008; Benson et al., 2009a,b; Bhattacharya and Jha, 2010; Laggari et al., 2009; Deeks et al., 2010). We postulated that a difference of similar magnitude would be clinically important. With 177 women with PCOS and 109 without PCOS, this study had 90% power to show a difference in a proportion of 20% in anxiety and depression with a two-sided P-value of 0.05.

Results

Recruitment and participation

A total of 470 women responded to recruitment advertisements; 374 were confirmed eligible (68 did not respond to email or phone call follow up for screening, 16 were ineligible owing to pregnancy, 6 owing to incomplete PCOS diagnosis, 2 owing to psychiatric illness, 2 lived overseas, 1 was over the upper age limit and 1 participant was deemed ineligible to participate because of a diagnosis of heart disease). The participation rate was 76% (286/374; 177 diagnosed with PCOS and 109 without diagnosed PCOS).

Demographics

The average age for women with PCOS was 32.8 years (±7.8) and without PCOS was 41.9 years (±15.4) years [difference (95% confidence interval (CI): 9.1 (6.4–11.8); P < 0.001]. The average BMI for women with and without PCOS was 31.5 (±7.9) and 24.5 (±5.4), respectively [difference (95% CI): 7.1 (5.4–8.8); P < 0.001]. Women with PCOS were less likely to be living alone [difference (95% CI): 9.4% (1.7–17.1%); P = 0.01] and/or to be working full-time [difference (95% CI): 12.7% (3.1–22.3%); P = 0.01] than those without PCOS. Women with PCOS were more likely to have been diagnosed with infertility [difference (95% CI): 40.3% (32.8–47.8%); P < 0.001] (Table I).

Table I

Demographic characteristics of women with and without PCOSa.

 PCOS (n = 177) Non-PCOS (n = 109) P-value 
Age (years) 32.8 ± 7.8 41.9 ± 15.4 <0.0001 
BMI (kg/m231.5 ± 7.9 24.5 ± 5.4 <0.0001 
Living in rural area (%) 26.9 20.2 0.2 
Living alone (%) 6.2 15.6 0.01 
Diagnosed infertility (%) 41.2 0.9 <0.0001 
Highest level of schooling (%) 
 Year 10 or below (students usually aged 15 years) 11.4 7.3 0.39 
 Year 11 or equivalent 8.5 11.9  
 Year 12 or equivalent (final year of secondary schooling, students aged 17–18 years) 80.1 80.8  
Work status (%) 
 No paid work 46.9 40.4 0.03 
 Part time 40.1 33.9  
 Full time 13.0 25.7  
Gross Household Income (Australian $) (%) 
 Below 40 000 (low income) 9.8 20.6 0.07 
 40 000–59 999 (low-mid income) 19.0 12.4  
 60 000–79 999 (middle income) 20.9 17.5  
 More than 80 000 (mid-high income) 50.3 49.5  
 PCOS (n = 177) Non-PCOS (n = 109) P-value 
Age (years) 32.8 ± 7.8 41.9 ± 15.4 <0.0001 
BMI (kg/m231.5 ± 7.9 24.5 ± 5.4 <0.0001 
Living in rural area (%) 26.9 20.2 0.2 
Living alone (%) 6.2 15.6 0.01 
Diagnosed infertility (%) 41.2 0.9 <0.0001 
Highest level of schooling (%) 
 Year 10 or below (students usually aged 15 years) 11.4 7.3 0.39 
 Year 11 or equivalent 8.5 11.9  
 Year 12 or equivalent (final year of secondary schooling, students aged 17–18 years) 80.1 80.8  
Work status (%) 
 No paid work 46.9 40.4 0.03 
 Part time 40.1 33.9  
 Full time 13.0 25.7  
Gross Household Income (Australian $) (%) 
 Below 40 000 (low income) 9.8 20.6 0.07 
 40 000–59 999 (low-mid income) 19.0 12.4  
 60 000–79 999 (middle income) 20.9 17.5  
 More than 80 000 (mid-high income) 50.3 49.5  

aValues are mean ± SD or proportions.

Psychological factors

In an examination of psychological factors, QOL (P < 0.001), self-worth (P < 0.0001) and aspects of body image were found to differ between women with and without PCOS (Tables II and III). The devised QOL measure was supported by use of the PCOSQ for which women with PCOS reported mean scores of 4.0 (SD = 1.4) for the Emotions domain, 3.7 (SD = 1.9) for Hair Growth, 2.7 (SD = 1.7) for Body Weight, 4.3 (SD = 1.7) for Infertility and 3.7 (SD = 1.3) for menstruation.

Table II

QOL and self-worth in women with and without PCOS (non-validated).

 PCOS (n = 177) Non-PCOS (n = 109) Overall P-value 
Quality of life 
 Mean ± SD 3.5 ± 0.9 3.8 ± 0.9 3.6 ± 0.9 <0.001 
 Range 1–5 1–5 1–5 
Self-worth 
 Mean ± SD 3.9 ± 0.9 4.4 ± 0.7 4.1 ± 0.9 <0.0001 
 Range 1–5 2–5 1–5 
 PCOS (n = 177) Non-PCOS (n = 109) Overall P-value 
Quality of life 
 Mean ± SD 3.5 ± 0.9 3.8 ± 0.9 3.6 ± 0.9 <0.001 
 Range 1–5 1–5 1–5 
Self-worth 
 Mean ± SD 3.9 ± 0.9 4.4 ± 0.7 4.1 ± 0.9 <0.0001 
 Range 1–5 2–5 1–5 
Table III

Psychological factors in women with and without PCOSa.

 PCOS (n = 177) Non-PCOS (n = 109) P-value 
Appearance evaluation 2.3 ± 0.9 3.1 ± 0.9 <0.0001 
Appearance orientation 3.5 ± 0.7 3.4 ± 0.7 0.39 
Fitness evaluation 3.2 ± 0.9 3.3 ± 0.9 0.32 
Fitness orientation 2.9 ± 0.9 3.4 ± 0.7 <0.0001 
Health evaluation 2.9 ± 0.8 3.6 ± 0.8 <0.0001 
Health orientation 3.4 ± 0.7 3.8 ± 0.6 <0.0001 
Illness orientation 3.0 ± 0.7 3.2 ± 0.7 0.1 
Body Areas Satisfaction Scale 2.6 ± 0.6 3.2 ± 0.6 <0.0001 
Overweight Preoccupation 3.4 ± 0.8 2.8 ± 0.9 <0.0001 
Self-classified weight 4.1 ± 0.8 3.4 ± 0.8 <0.0001 
HADS anxietyb 9.5 ± 3.9 6.5 ± 3.6 <0.001 
HADS depressionb 5.7 ± 3.7 3.3 ± 3.1 <0.001 
 PCOS (n = 177) Non-PCOS (n = 109) P-value 
Appearance evaluation 2.3 ± 0.9 3.1 ± 0.9 <0.0001 
Appearance orientation 3.5 ± 0.7 3.4 ± 0.7 0.39 
Fitness evaluation 3.2 ± 0.9 3.3 ± 0.9 0.32 
Fitness orientation 2.9 ± 0.9 3.4 ± 0.7 <0.0001 
Health evaluation 2.9 ± 0.8 3.6 ± 0.8 <0.0001 
Health orientation 3.4 ± 0.7 3.8 ± 0.6 <0.0001 
Illness orientation 3.0 ± 0.7 3.2 ± 0.7 0.1 
Body Areas Satisfaction Scale 2.6 ± 0.6 3.2 ± 0.6 <0.0001 
Overweight Preoccupation 3.4 ± 0.8 2.8 ± 0.9 <0.0001 
Self-classified weight 4.1 ± 0.8 3.4 ± 0.8 <0.0001 
HADS anxietyb 9.5 ± 3.9 6.5 ± 3.6 <0.001 
HADS depressionb 5.7 ± 3.7 3.3 ± 3.1 <0.001 

aValues are mean ± SD.

bA cut-off score of 8 and above for the HADS was used to indicate that an anxiety or depressive disorder was present.

Results from the MBSRQ found that women with PCOS had lower appearance evaluation, fitness orientation, health evaluation, health orientation, body areas satisfaction, higher overweight preoccupation and higher self-classified weight than women without PCOS (Table III).

Levels of anxiety and depression were found to differ between women with and without PCOS (Table III). Women with PCOS had a higher mean anxiety score (P < 0.001) and a higher mean depression score (P < 0.001), compared with women without PCOS.

Univariate linear regression for women with PCOS showed that poorer perception of QOL, self-worth, appearance evaluation, fitness orientation, health evaluation, health orientation, body areas satisfaction and higher overweight preoccupation resulted in higher levels of anxiety and depression (Tables IV and V). More negative appearance orientation, fitness evaluation and higher BMI also predicted increased levels of depression but not anxiety in women with PCOS (Table V).

Table IV

Predictors of anxiety in women with and without PCOS—univariate linear regression.

Variable PCOS
 
Non-PCOS
 
 PE (SE) P-value PE (SE) P-value 
Age (years) −0.1 (0.04) 0.06 −0.01 (0.02) 0.55 
BMI (kg/m2) 0.02 (0.04) 0.57 −0.04 (0.06) 0.5 
Living in rural area −0.2 (0.7) 0.72 1.0 (0.8) 0.25 
Living alone −1.1 (1.2) 0.37 −0.4 (0.9) 0.64 
Diagnosed infertility −0.7 (0.6) 0.27 −5.5 (3.5) 0.12 
Highest level of schooling 
Year 10 or belowa     
Year 11 or equivalent 0.3 (1.3) 0.8 3.2 (1.6) 0.05 
Year 12 or equivalent 0.6 (0.9) 0.5 0.9 (1.3) 0.48 
Work status 
No paid worka     
Part time 0.06 (0.94) 0.95 −1.2 (0.9) 0.18 
Full time 0.87 (0.92) 0.35 −2.3 (0.8) 0.01 
Income (dollar) 
Below 40 000a     
40 000–59 999 2.1 (1.2) 0.09 −2.1 (1.2) 0.09 
60 000–79 999 0.7 (1.2) 0.54 −4.1 (1.1) 0.001 
80 000 and above 0.4 (1.1) 0.71 −2.1 (0.9) 0.02 
Appearance evaluation −1.7 (0.3) <0.001 −0.6 (0.4) 0.11 
Appearance orientation 0.3 (0.4) 0.44 −0.03 (0.5) 0.96 
Fitness evaluation −0.5 (0.3) 0.09 −0.4 (0.4) 0.28 
Fitness orientation −0.7 (0.3) 0.03 −0.3 (0.5) 0.54 
Health evaluation −2.0 (0.3) <0.001 −1.6 (0.4) <0.001 
Health orientation −1.0 (0.4) 0.02 −0.03 (0.6) 0.96 
Illness orientation −0.6 (0.4) 0.15 −0.5 (0.5) 0.29 
Body Areas Satisfaction Scale −1.6 (0.4) 0.001 −0.7 (0.6) 0.18 
Overweight preoccupation 0.9 (0.3) 0.01 0.3 (0.4) 0.46 
Self-classified weight 0.6 (0.4) 0.1 −0.3 (0.4) 0.54 
Quality of life −1.3 (0.3) <0.001 −1.3 (0.4) 0.001 
Self-worth −2.1 (0.3) <0.001 −1.6 (0.5) 0.001 
Time to PCOS diagnosis 0.6 (0.2) 0.01 N/A N/A 
Variable PCOS
 
Non-PCOS
 
 PE (SE) P-value PE (SE) P-value 
Age (years) −0.1 (0.04) 0.06 −0.01 (0.02) 0.55 
BMI (kg/m2) 0.02 (0.04) 0.57 −0.04 (0.06) 0.5 
Living in rural area −0.2 (0.7) 0.72 1.0 (0.8) 0.25 
Living alone −1.1 (1.2) 0.37 −0.4 (0.9) 0.64 
Diagnosed infertility −0.7 (0.6) 0.27 −5.5 (3.5) 0.12 
Highest level of schooling 
Year 10 or belowa     
Year 11 or equivalent 0.3 (1.3) 0.8 3.2 (1.6) 0.05 
Year 12 or equivalent 0.6 (0.9) 0.5 0.9 (1.3) 0.48 
Work status 
No paid worka     
Part time 0.06 (0.94) 0.95 −1.2 (0.9) 0.18 
Full time 0.87 (0.92) 0.35 −2.3 (0.8) 0.01 
Income (dollar) 
Below 40 000a     
40 000–59 999 2.1 (1.2) 0.09 −2.1 (1.2) 0.09 
60 000–79 999 0.7 (1.2) 0.54 −4.1 (1.1) 0.001 
80 000 and above 0.4 (1.1) 0.71 −2.1 (0.9) 0.02 
Appearance evaluation −1.7 (0.3) <0.001 −0.6 (0.4) 0.11 
Appearance orientation 0.3 (0.4) 0.44 −0.03 (0.5) 0.96 
Fitness evaluation −0.5 (0.3) 0.09 −0.4 (0.4) 0.28 
Fitness orientation −0.7 (0.3) 0.03 −0.3 (0.5) 0.54 
Health evaluation −2.0 (0.3) <0.001 −1.6 (0.4) <0.001 
Health orientation −1.0 (0.4) 0.02 −0.03 (0.6) 0.96 
Illness orientation −0.6 (0.4) 0.15 −0.5 (0.5) 0.29 
Body Areas Satisfaction Scale −1.6 (0.4) 0.001 −0.7 (0.6) 0.18 
Overweight preoccupation 0.9 (0.3) 0.01 0.3 (0.4) 0.46 
Self-classified weight 0.6 (0.4) 0.1 −0.3 (0.4) 0.54 
Quality of life −1.3 (0.3) <0.001 −1.3 (0.4) 0.001 
Self-worth −2.1 (0.3) <0.001 −1.6 (0.5) 0.001 
Time to PCOS diagnosis 0.6 (0.2) 0.01 N/A N/A 

aReference category, PE, parameter estimate.

Table V

Predictors of depression in women with and without PCOS—univariate linear regression.

Variable PCOS
 
Non-PCOS
 
 PE (SE) P-value PE (SE) P-value 
Age (years) −0.03 (0.04) 0.37 0.01 (0.02) 0.48 
BMI (kg/m20.1 (0.03) 0.004 0.07 (0.06) 0.24 
Living in rural area −0.1 (0.6) 0.92 −0.6 (0.8) 0.46 
Living alone 0.4 (1.2) 0.75 −0.4 (0.8) 0.66 
Diagnosed infertility −0.4 (0.6) 0.45 −0.3 (3.2) 0.92 
Highest level of schooling 
 Year 10 or belowa     
 Year 11 or equivalent 0.9 (1.3) 0.47 −0.3 (1.4) 0.84 
 Year 12 or equivalent −0.7 (0.9) 0.43 −0.9 (1.2) 0.41 
Work status 
 No paid worka     
 Part time −0.1 (0.9) 0.93 −0.1 (0.8) 0.88 
 Full time −0.5 (0.9) 0.59 −1.4 (0.7) 0.06 
Income (dollars) 
 Below 40 000a     
 40 000–59 999 1.9 (1.1) 0.08 −0.9 (1.1) 0.41 
 60 000–79 999 0.9 (1.1) 0.43 −2.2 (1.0) 0.04 
 80 000 and above −0.4 (1.0) 0.67 −1.5 (0.8) 0.06 
 Appearance evaluation −2.2 (0.3) <0.001 −1.2 (0.3) <0.001 
 Appearance orientation −1.0 (0.4) 0.01 −0.9 (0.4) 0.04 
 Fitness evaluation −0.8 (0.3) 0.01 −0.9 (0.3) 0.01 
 Fitness orientation −1.7 (0.3) <0.001 −1.1 (0.4) 0.01 
 Health evaluation −2.3 (0.3) <0.001 −1.6 (0.3) <0.001 
 Health orientation −2.0 (0.4) <0.001 −1.4 (0.5) 0.01 
 Illness orientation −0.7 (0.4) 0.06 −1.4 (0.4) 0.001 
 Body Areas Satisfaction Scale −2.4 (0.4) <0.001 −1.5 (0.5) 0.001 
 Overweight preoccupation 0.6 (0.3) 0.06 0.2 (0.3) 0.64 
 Self-classified weight 1.4 (0.3) <0.001 0.2 (0.4) 0.57 
 Quality of life −1.8 (0.3) <0.001 −1.8 (0.3) <0.001 
 Self-worth −2.0 (0.3) <0.001 −2.1 (0.4) <0.001 
 Time to PCOS diagnosis 0.5 (0.2) 0.03 N/A N/A 
Variable PCOS
 
Non-PCOS
 
 PE (SE) P-value PE (SE) P-value 
Age (years) −0.03 (0.04) 0.37 0.01 (0.02) 0.48 
BMI (kg/m20.1 (0.03) 0.004 0.07 (0.06) 0.24 
Living in rural area −0.1 (0.6) 0.92 −0.6 (0.8) 0.46 
Living alone 0.4 (1.2) 0.75 −0.4 (0.8) 0.66 
Diagnosed infertility −0.4 (0.6) 0.45 −0.3 (3.2) 0.92 
Highest level of schooling 
 Year 10 or belowa     
 Year 11 or equivalent 0.9 (1.3) 0.47 −0.3 (1.4) 0.84 
 Year 12 or equivalent −0.7 (0.9) 0.43 −0.9 (1.2) 0.41 
Work status 
 No paid worka     
 Part time −0.1 (0.9) 0.93 −0.1 (0.8) 0.88 
 Full time −0.5 (0.9) 0.59 −1.4 (0.7) 0.06 
Income (dollars) 
 Below 40 000a     
 40 000–59 999 1.9 (1.1) 0.08 −0.9 (1.1) 0.41 
 60 000–79 999 0.9 (1.1) 0.43 −2.2 (1.0) 0.04 
 80 000 and above −0.4 (1.0) 0.67 −1.5 (0.8) 0.06 
 Appearance evaluation −2.2 (0.3) <0.001 −1.2 (0.3) <0.001 
 Appearance orientation −1.0 (0.4) 0.01 −0.9 (0.4) 0.04 
 Fitness evaluation −0.8 (0.3) 0.01 −0.9 (0.3) 0.01 
 Fitness orientation −1.7 (0.3) <0.001 −1.1 (0.4) 0.01 
 Health evaluation −2.3 (0.3) <0.001 −1.6 (0.3) <0.001 
 Health orientation −2.0 (0.4) <0.001 −1.4 (0.5) 0.01 
 Illness orientation −0.7 (0.4) 0.06 −1.4 (0.4) 0.001 
 Body Areas Satisfaction Scale −2.4 (0.4) <0.001 −1.5 (0.5) 0.001 
 Overweight preoccupation 0.6 (0.3) 0.06 0.2 (0.3) 0.64 
 Self-classified weight 1.4 (0.3) <0.001 0.2 (0.4) 0.57 
 Quality of life −1.8 (0.3) <0.001 −1.8 (0.3) <0.001 
 Self-worth −2.0 (0.3) <0.001 −2.1 (0.4) <0.001 
 Time to PCOS diagnosis 0.5 (0.2) 0.03 N/A N/A 

aReference category.

In women without PCOS, lower perceived QOL and self-worth resulted in higher levels of anxiety along with achieving only year 11 schooling, not working full-time, a lower household income and lower health evaluation (Table IV). More negative appearance evaluation and orientation, fitness evaluation and orientation, health evaluation and orientation, illness orientation, body areas satisfaction, self-worth and QOL predicted increased levels of depression in women without PCOS (Table V).

Multivariate regressions for anxiety and depression

Multivariate linear regressions were used to further examine the effect of demographic and psychological factors on the presence of anxiety and depression. Multivariate linear regression in women with PCOS showed that factors independently associated with anxiety were health evaluation [PE –1.0 (SE 0.3); P = 0.005], self-worth [PE –1.7 (SE 0.3); P < 0.0001], age (PE –0.08 (SE 0.03); P = 0.02] and time taken to diagnosis of PCOS [PE 0.6 (SE 0.2); P = 0.003].

The factors independently associated with depression in women with PCOS were appearance evaluation [PE –1.1 (SE 0.3); P = 0.001], fitness orientation [PE –0.9 (SE 0.3); P = 0.002], self-worth [PE –1.1 (SE 0.3); P = 0.0004], QOL [PE –0.8 (SE 0.3); P = 0.00] and time taken to diagnose PCOS [PE 0.4 (SE 0.2); P = 0.03].

Multivariate linear regression in women without PCOS showed that the factors independently associated with anxiety were health evaluation [PE –1.5 (SE 0.4); P = 0.001], self-worth [PE –1.3 (SE 0.5); P = 0.009] and living in a rural location [PE –1.8 (SE 0.8); P = 0.03].

The factors independently associated with depression in women without PCOS were appearance orientation [PE –0.8 (SE 0.3); P = 0.02], illness orientation (PE –1.2 (SE 0.3); P = 0.001], QOL [PE –1.3 (SE 0.3); P < 0.0001] and self-worth [PE –1.7 (SE 0.3); P < 0.0001].

Discussion

In this study, we found that mood was significantly compromised in women with PCOS. Further, this study confirms the association of PCOS with anxiety and depression and we note that the longer it takes to receive a diagnosis of PCOS, the more likely women are to be depressed or anxious. Negative body image and poor perception of self-worth appear to be associated with both anxiety and depression in women and reporting poor QOL and dissatisfaction with appearance are key influences on depression. Women with PCOS report not liking the way they look, or the way that clothes fit them and they do not feel their body is sexually appealing. That women were less likely to feel that they were ‘worthwhile’ negatively impacted on mood. Less investment in fitness was linked to depression in women with PCOS, whereas increased investment in health was associated with anxiety in all women.

This study confirms previous research that anxiety and depression are more prevalent in women with PCOS (Gold et al., 2002; Wilhelm et al., 2003; Mansson et al., 2008; Bhattacharya and Jha 2010; Deeks et al., 2010; Jedel et al., 2010). Furthermore, the current study showed that anxiety and depression are generally more severe in women with PCOS; particularly troubling when general population studies are considered and compared. The interrelationship of anxiety, depression and physical illness is important to consider in women with PCOS. As negative mood can impact on physical (e.g. eating and sleeping patterns), psychological (e.g. motivation and feelings of worthlessness) and social factors (e.g. relationships with others), effective symptom management of PCOS is likely to be improved if existing anxiety and depression are effectively treated. Therefore, it is vital that women with PCOS are screened and assessed for anxiety and depression and offered appropriate interventions if required.

It is important to note that anxiety and depression were higher in women with PCOS after accounting for BMI and age. Consistent with prior literature, women with PCOS in the current study had a higher BMI and BMI is known to adversely impact on mood. Importantly, we report that even those women who were leaner and who had PCOS were also likely to have anxiety and depression. The findings from this study suggest that it is important to consider the effects of PCOS per se on body image and its relationship with mood, independent of BMI. In a study of QOL, psychosocial wellbeing and sexual satisfaction, Elsenbruch et al. (2003) found that BMI had no impact on ratings of obsessive compulsive, interpersonal sensitivity, depression and psychoticism using the SCL-90-R. Other research has found that even women with PCOS who have a normal BMI still have difficulties with their weight (Coffey et al., 2006; Jones et al., 2008a).

In general, women with PCOS had lower scores on appearance evaluation than controls, and women with lower scores on appearance evaluation were more likely to be depressed. Women with PCOS were less likely to feel that others would consider them good looking, they were more likely to dislike their physique, did not feel as sexually appealing and felt more physically unattractive than controls. The physical symptoms of PCOS, such as hirsutism and acne, may have made these women more focused on their appearance, implying a need to do something about their appearance, which ultimately may lead to increased depression. Placing greater emphasis on satisfaction with their health may make women with PCOS more anxious. Women who were less invested in their physical fitness were more likely to be depressed, and women with PCOS had lower satisfaction with their fitness than women without PCOS. This suggests that women with PCOS who valued fitness and were more likely to be involved in physical activity were not as depressed as those with low scores on fitness orientation. Not only should lifestyle, including physical activity, be first line treatment in the majority of women with PCOS (Moran et al., 2010) but physical activity has also been linked to improved mood. Women with PCOS should be encouraged to pursue physical activity for both symptom management and psychological benefits.

Perception of self-worth has been found (Beard et al., 2008; Rofey et al., 2009) to influence mood; so it is little surprise that both women with and without PCOS who had lower scores of self-worth were also more likely to be depressed and anxious. Coping resources are often compromised in people with low self-worth, increasing vulnerability to depression and anxiety, an important consideration given that women with PCOS had even lower perceived self-worth scores than women without. The current findings suggest that self-worth should be explored in PCOS and appropriate treatment offered if needed.

This study confirms previous research showing that QOL is reduced in PCOS (Coffey et al., 2006; Avery and Braunack-Mayer, 2007; Barnard et al., 2007; Jones et al., 2008a,b) and further suggests that reduced QOL is associated with depression in women both with and without PCOS; however, it may not be a predictor of anxiety. Subscale scores of the PCOSQ in the current study are similar to those found by past researchers; in particular, weight was also the lowest scoring domain (as found by Coffey et al., 2006; Jones et al., 2008a) once more reinforcing the need to consider the reduced QOL of women with PCOS. In a large population-based study, researchers found that depression in diabetes was an important co-morbidity to treat, particularly because of its severe impact on QOL (Goldney et al., 2004). The additive effects of depression and poor QOL may impact adversely on physical symptoms, medication adherence and lifestyle management. The same may be true for women with PCOS, highlighting the need to address depression and QOL in PCOS management. It is difficult to know whether it is depression that influences perceived QOL or that poor perception of QOL increases depression. Generally, people use their current affective state to judge their overall current QOL, including wellbeing, social functioning and living conditions (Moore et al., 2005), and treating depression is likely to improve the overall current QOL. It is likely that for women with PCOS, concurrent treatment of depression and PCOS symptoms could therefore mean an improved QOL.

Finally, it is very important to acknowledge that in the current study, the longer time to PCOS diagnosis predicted increased anxiety and depression. Without a diagnosis and hence an explanation for excess hair growth, acne and irregular periods, women are likely to experience increased distress and as a consequence Kitzinger and Willmott (2002) reported that women without a diagnosis often felt ‘freakish’, ‘abnormal’ and not ‘proper’. Greater education of health professionals and consumers to improve the time to diagnosis is needed to address this important finding and therefore reduce the psychological impact in women with PCOS.

There are some limitations in the current study. This was a community sample of self-selecting women which, although more representative than a clinic population, potentially limits generalizability of results by the nature of women who volunteer to participate. Not being able to verify the diagnosis of PCOS through medical records was a limitation of the study; however, participants required a pre-existing medical diagnosis of PCOS, confirmed by screening carried out by a skilled PCOS researcher, supported by an experienced endocrinologist. Also, further questioning contained within the surveys was used to confirm PCOS diagnosis. Measurement using validated scales of self-worth and QOL may also have allowed further discussion and understanding of the specific areas of self-worth and QOL that contributed to negative mood (e.g. physical, social functioning and/or living conditions for QOL). Future research would benefit from matching women with PCOS and without PCOS on age and BMI, as even though these variables were controlled for in the present study, they are likely to be important influencing factors for any understanding of psychological function in PCOS.

In this large comprehensive community-based study, women with PCOS had increased prevalence and severity of anxiety and depression compared with controls, with significant implications for the clinical assessment and treatment of PCOS. Consideration, comprehensive assessment and management of mood in women with PCOS are vital. Increased education and awareness of PCOS symptoms to improve the time to diagnosis would be beneficial. Regular screening, assessment and treatment of anxiety and depression in women with PCOS are likely to result in improved self-worth and QOL and, ultimately, effective management of symptoms in women with PCOS.

Authors' roles

A.A.D. participated in study design, execution, analysis, manuscript drafting and critical discussion. M.E.G.H. participated in study execution, analysis, manuscript drafting and critical discussion. E.P. participated in study analysis, manuscript drafting and critical discussion. H.J.T. participated in study design, analysis, manuscript drafting and critical discussion.

Funding

This project is supported by a BRIDGES grant from the Global Diabetes Foundation. BRIDGES, an International Diabetes Federation project, is supported by an educational grant from Lilly Diabetes (Project Number: LT07-121). H.J.T. is supported by an NH&MRC research fellowship.

Acknowledgements

The authors acknowledge Lauren Snell for her assistance in final manuscript preparation and editing.

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