Bridging the Gap: Integrating Awareness of Polycystic Ovary Syndrome Into Mental Health Practice

The majority of research evaluating the link between PCOS and comorbid mental health conditions has focused on depression. These investigations typically utilize cross-sectional study designs and self-assessments, such as the Beck Depression Inventory, to measure the presence and severity of depressive symptoms (9). In a comprehensive meta-analysis that involved over 3,000 subjects and specifically focused on studies adhering to rigorous PCOS diagnostic criteria, Cooney et al. (2017) showed that individuals with PCOS were more than twice as likely to experience depressive symptoms (36% vs. 14%) and had four times higher odds of experiencing moderate to severe levels of depressive symptoms compared with individuals without PCOS (10).

In contrast to the growing scientific literature on PCOS and depressive symptoms, only a few studies have used formal psychiatric interviews to diagnose depressive disorders, and even fewer studies have examined the longitudinal trajectory (neither over an extended time nor across reproductive transitions) of depressive symptoms among individuals with PCOS. In one of the few longitudinal investigations assessing the prevalence of psychiatric disorders in women with PCOS, Kerchner et al. (2007) reported that nearly 60% of the subjects exhibited a depressive disorder, with an additional 19% developing a depressive disorder during the 2-year follow-up (11). In a study of Taiwanese women who had been diagnosed as having PCOS and tracked for up to a decade, those with PCOS had higher odds of developing depressive disorders compared with matched controls (12).

Although some studies have identified connections between increased depression rates in people with PCOS and factors such as higher body mass index (BMI), hirsutism, infertility, or acne (13), other research supports the presence of elevated depressive symptoms independent from these associated conditions (11, 14). In a large Swedish registry study, Cesta et al. (2016) conducted a comparative analysis involving women with PCOS, unaffected female twins, and women without PCOS. The outcomes revealed that, compared with individuals without PCOS in the broader population, PCOS-affected twins exhibited the highest risk of depression, followed by their unaffected siblings (4). Notably, an estimated 63% of the depression risk was attributed to shared genetic factors among twins, whereas the remaining portion was linked to PCOS-specific pathological factors. This underscores the dual role of genetic and PCOS-specific components in contributing to the heightened risk of depression that was not only observed in women with PCOS but also extended to their female siblings.

Although not as extensively explored as depression, there is growing research demonstrating increased levels of anxiety among individuals with PCOS. A meta-analysis encompassing over 50 studies found that those with PCOS exhibit a notably elevated likelihood of experiencing anxiety disorders (odds ratio [OR]=2.75; 95% confidence interval [CI]=2.10–3.60) and obsessive-compulsive disorder (OR=1.37; 95% CI=1.22–1.55), compared with individuals without PCOS (5). Additionally, another study revealed increased rates of generalized anxiety disorder and social anxiety disorder, although not obsessive-compulsive disorder (15).

It is interesting that the prevalence and severity of anxiety symptoms among individuals with PCOS is even more pronounced than those of depressive symptoms. In a meta-analysis by Cooney et al. (2017), those with PCOS had five times higher odds of experiencing anxiety symptoms and almost six times higher odds of having moderate to severe levels of anxiety symptoms compared with controls (16). As with depression, the literature presents diverse viewpoints. Although some studies indicate a connection between anxiety symptoms and factors such as higher BMI, hirsutism, or free testosterone (17–19), others establish associations independent of these factors and across different PCOS phenotypes (16). At this time, however, there are no known studies focusing on the biological causes of the elevated rates of anxiety observed among individuals with PCOS.

Although anxiety and depression have been the primary focus of research efforts, more recent studies have noted an association of PCOS with other psychiatric disorders, such as bipolar disorder. A meta-analysis conducted by Brutocao et al. (5) indicated that 5% of participants with PCOS in the analyzed studies had bipolar disorder, a rate higher than that of controls. In a separate study by Cesta et al. (4), participants with PCOS in their sample exhibited an elevated risk of developing new incidences of bipolar disorder in comparison with controls. However, studies in various global regions have failed to establish this connection (12), reinforcing the need for more research in this area.

Perhaps related to the higher rates of obesity, lower self-esteem, and difficulty with weight loss, individuals with PCOS exhibit higher levels of body dissatisfaction (20, 21). One biological explanation for this trend is the connection between changes in sex hormones—especially heightened androgens—and increased hunger, along with diminished satiety signaling from the orexigenic hormone, ghrelin, and increased insulin resistance (22). Consistent with these findings, individuals with PCOS face an elevated susceptibility not only to disordered eating (behaviors including binge eating, laxative abuse, and restricting behaviors that do not rise to the level of DSM diagnostic criteria) (12, 23) but also to pathological eating disorders (4). Lee et al. (2017) conducted a study revealing that individuals with PCOS reported significantly higher scores on the Eating Disorder Examination Questionnaire and exhibited an increased prevalence of bulimia nervosa compared with control participants. Although there was also a trend toward higher rates of binge eating disorder, it did not achieve statistical significance (24). One study (14) found a 12.6% prevalence of binge eating disorder among participants with PCOS, compared with 1.9% in controls without PCOS. These findings were corroborated by two separate meta-analyses, indicating an elevated likelihood of bulimia nervosa or binge eating disorder among individuals with PCOS, especially in those with higher BMIs or concurrent depression and anxiety (24, 25).

Considering these results, mental health professionals should proactively screen for eating disorders in individuals with PCOS (see Table 1) and simultaneously address depression and anxiety to mitigate these risks (26). Additionally, in selecting psychotropic medications with potential metabolic side effects, it is crucial to consider both BMI and the heightened risk for insulin resistance among patients with PCOS, the latter of which is observed in both overweight and lean individuals with PCOS. Although some studies suggest improvements in satiety signaling and overeating with insulin-sensitizing treatments, it is uncertain whether similar benefits extend to those with PCOS and binge eating disorders (27).

With a growing recognition of the elevated rates of psychiatric comorbidity among individuals with PCOS, larger cohort studies have been able to explore the prevalence of less common psychiatric conditions or symptoms. For instance, Cesta et al. (2016) found increased rates of schizophrenia, personality disorders, autism spectrum disorders, and tic disorders among participants with PCOS compared with matched controls from the general population (4). There is also evidence of heightened rates (sometimes up to twice as high) of sleep disorders such as obstructive sleep apnea and excessive daytime sleepiness in individuals with PCOS. These associations remained elevated even after adjusting for BMI (12, 28, 29). Considering the established bidirectional connection between psychiatric symptoms and sleep disorders, these findings underscore the importance of screening for excess daytime fatigue and evaluating sleep quality in women with PCOS.

Notably, individuals with PCOS have been shown to have a higher prevalence of both suicidal thoughts and suicide attempts, with one study estimating a sevenfold increase in suicide attempts among participants with PCOS compared with a control group (30). Another more recent study showed a 40% increased risk of attempted suicide in individuals with PCOS, but this difference was not significant when controlling for other mental health conditions (9). This suggests that the higher risk of suicide attempts may result from the greater presence of mental health concerns generally among individuals with PCOS. Williams et al. (2022) found that those with PCOS were more likely to engage in nonsuicidal self-injury, think about suicide, struggle with controlling their emotions, and engage in rumination (29, 31), which may also contribute to the increased rates of suicidal thoughts or attempts observed in previous studies. Last, several studies have demonstrated elevated rates of neuroticism as well as traits related to specific personality dimensions (schizotypal, borderline, and paranoid) that may contribute to the elevated mental health scores and conditions observed among individuals with PCOS (32).

Initial studies on mental health outcomes among adults with PCOS disproportionally focused on how its co-occurring medical conditions contribute to psychological distress and diminished overall QoL. To gauge the impact of PCOS and its treatments on various aspects of life, health-related QoL (HR-QoL) emerged as a crucial metric, encompassing physical, mental, and perceived functioning. Many of the challenges faced by women with PCOS (e.g., infertility, hirsutism, irregular menstrual cycles, and weight concerns) contribute to psychosocial distress. Researchers have undertaken comprehensive evaluations, utilizing validated measures (refer to Table 1), to uncover notable reductions in HR-QoL across all these domains (6, 25, 26, 33, 34). A 2015 meta-analysis by Bazarganipour et al. highlighted hirsutism and irregular menstruation as the most common factors contributing to decreased QoL in women with PCOS (35). Notably, this study also revealed that the effect of PCOS on QoL is comparable with the effects of other serious chronic conditions (e.g., asthma, migraine, and rheumatoid arthritis) and underscores the substantial burden that this syndrome places on the well-being of those affected (30). Considering the importance of these findings, the integration of HR-QoL measures into the long-term psychiatric care of patients with PCOS has the potential to elevate awareness concerning the diverse life domains affected by the condition. Additionally, this approach can offer valuable guidance in tailoring treatment interventions (see Table 1; see also “Addressing Psychiatric Symptoms in PCOS: Treatment Approaches” section) and facilitating medical referrals, ultimately leading to more comprehensive management of the syndrome (26).

As described earlier, PCOS can affect multiple domains of an individual’s life, including general medical health, mental health, and daily functioning. The infertility, hirsutism, menstrual cycle irregularities, and weight gain that can come with PCOS may contribute to psychosocial distress and reduce a person’s QoL (30). Thus, interventions to improve QoL in PCOS may focus on managing symptoms such as weight gain, insulin resistance, hirsutism, and acne (62) or on improving menstrual cycle regularity and fertility.

A key lifestyle intervention in PCOS is dietary modification and exercise to promote weight loss, combat insulin resistance, and restore menstrual regularity. Clinical studies have assessed the impact of lifestyle modification and exercise on QoL and mood in PCOS. A study that compared different physical exercise interventions found that continuous aerobic training, intermittent aerobic training, and progressive resistance training over 16 weeks each improved scores on the Hospital Anxiety and Depression Scale (HADS) more than a control condition among individuals with PCOS (63), similar to the results in a previous study (64). Intermittent aerobic training was the most effective of the exercise interventions in improving QoL and depressive symptoms (63). A study comparing dietary intervention alone or combined with exercise over 20 weeks found that both interventions improved depressive symptoms and QoL in PCOS (65). However, neither of these studies assessed whether benefits were maintained over time; specifically, whether weight was eventually regained or how durable the impact on depressive symptoms was beyond the 16- and 20-week interventions. A three-component intervention including diet, exercise, and cognitive-behavioral therapy (CBT) reduced depressive symptoms in PCOS over 1 year, suggesting that benefits are maintained over time while in an active intervention (66). It is interesting that weight loss did not mediate the effects of the intervention on depressive symptoms, which suggests that lifestyle interventions can reduce depressive symptoms independent of weight loss in PCOS.

Psychotherapy can be beneficial for managing psychiatric symptoms that occur with PCOS. CBT is an empirically supported intervention for affective disorders, including depressive disorders and anxiety disorders. CBT is a structured, time-limited form of therapy that focuses on managing affective symptoms by identifying and modifying maladaptive cognitions and behaviors. CBT includes specific tools such as behavioral activation, identifying cognitive distortions, and restructuring negative cognitions. These tools are usually delivered in weekly 60-minute sessions over the course of 8–12 weeks.

Two recent meta-analyses have found CBT interventions beneficial for affective symptoms in PCOS. One assessed eight trials comparing CBT to lifestyle modification or routine treatment and found that CBT significantly improved anxiety symptoms but not depressive symptoms or QoL (67). A meta-analysis of four trials found that CBT was effective in reducing depressive symptoms in PCOS (68). Given these generally positive findings for CBT in women with PCOS, psychiatric care providers may consider including CBT, alone or with medication, for those with PCOS who experience depressive or anxiety symptoms.

An emerging empirically supported intervention is mindfulness-based psychotherapy, which is operationalized as mindfulness-based stress reduction (MBSR) or mindfulness-based cognitive therapy. These interventions include individual or group therapy sessions focusing on principles such as nonjudging and present-focused awareness and using structured mindfulness meditations. Numerous recent trials have assessed mindfulness-based interventions in PCOS. An initial study of a self-guided individual MBSR intervention in psychiatrically healthy PCOS individuals found that, over 8 weeks, MBSR reduced depressive symptoms, anxiety, and stress in comparison with a no-intervention control condition (69). Other studies have assessed group mindfulness interventions. Recently, an 8-week MBSR group program among individuals with PCOS improved QoL, anxiety symptoms, and perceived stress but not depressive symptoms (70). These participants were psychiatrically healthy (indeed, current depression was an exclusion criterion), so results may not generalize to those with PCOS and a psychiatric diagnosis. Furthermore, there was no comparison group that might control for the effects of social support that comes with the weekly 2-hour sessions. A similar recent study found that twice-weekly group MBSR sessions over 1 month reduced worry symptoms in individuals with PCOS compared with a control treatment-as-usual condition (71). Similar to those in the aforementioned group MBSR study, the participants were psychiatrically healthy, and the control condition did not account for group social support effects. A 3-month mindful yoga intervention improved anxiety and depressive symptoms in individuals with PCOS; group sessions were thrice weekly compared with a no-intervention control condition, again making it difficult to disentangle effects of mindfulness from those of group social support (72). Although the results of MBSR interventions in PCOS have been generally positive, there is at least one study with negative results. A 5-week, mindfulness-based healthy lifestyle group intervention in young adults with PCOS did not significantly improve anxiety or depressive symptoms compared with a waitlist control condition (73). Thus, mindfulness interventions show promise in treating PCOS, but clinical trials that focus specifically on PCOS with comorbid affective disorders are needed as well as studies of group MBSR interventions that include a valid comparison group intervention to control for social support effects that are inherent to a group intervention.

There is surprisingly little research on psychotropic medications for treating affective symptoms in patients with PCOS. In fact, a 2013 Cochrane review found only one study that assessed psychiatric medication in PCOS (74), and, surprisingly, it did not assess mood outcomes (75). Similarly, a 2018 study assessed the use of escitalopram in individuals with PCOS but who had no comorbid affective diagnosis, and it found that 12 weeks of 20 mg escitalopram had no impact on depressive symptoms or HR-QoL compared with placebo (76). It is likely that, because these participants were not clinically depressed, there was little room for improvement in depressive symptoms. However, among those with PCOS and mild to moderate depression, a 6-week intervention of 50 mg sertraline significantly improved depressive symptom severity (77). More research is needed on psychotropic medications for affective symptoms in PCOS, with attention to whether individuals with PCOS metabolize and respond to psychotropics in a manner similar to that of individuals without PCOS. For those with PCOS and moderate to severe mood symptoms for which psychiatric medication is an option, psychotropics that are more weight neutral (e.g., sertraline and fluoxetine) or that even aid in weight loss (e.g., bupropion) are preferred.

A small body of research has evaluated whether supplements and vitamins improve some of the signs and symptoms of PCOS, including mental health outcomes (namely, depressive symptoms) after treatment. Low levels of vitamin D have been previously associated with depressive symptoms, with some evidence of improvement after supplementation (78, 79). Although some studies support higher rates of vitamin D deficiency among individuals with PCOS, others have not found differences between controls and PCOS-affected patients (80, 81). However, all studies supported the link between low vitamin D, elevated depressive symptoms, and increased inflammatory markers (82). In two small randomized controlled trials—one combining vitamin D with probiotic supplementation and the other with omega-3 fatty acids—the intervention arms showed significant reductions in scores on depression, anxiety, and stress scales compared with scores for controls (56, 83). Notably, these studies, as well as those evaluated by a large meta-analysis, showed significant improvements in hormone profiles (reduced testosterone) and proinflammatory markers (reduced C-reactive protein) with vitamin D supplementation (84). Taken together, although it will be important for future studies to expand on and replicate these findings, there is sufficient evidence from this body of work, and from our knowledge of the intersection of vitamin D with inflammation and depressive symptoms more generally, to recommend testing of vitamin D levels among individuals with PCOS and the consideration of supplementation to target both psychiatric and physical symptoms.

Most studies of oral contraceptives (OCPs) in individuals with PCOS have focused on metabolic outcomes, not mood outcomes. An early study found that women with PCOS who were using OCPs had lower scores on the Center for Epidemiological Studies–Depression Rating Scale than those who were not using OCPs (85). A 6-month course of ethinyl estradiol/drospirenone in a small sample improved scores on the emotional domain on the Polycystic Ovary Syndrome Questionnaire but had no significant impact on depression or anxiety scores (86). However, in the large, rigorously designed Treatment of Hyperandrogenism vs. Insulin Resistance in Infertile PCOS Women (OWL-PCOS) intervention study, a low-dose continuous OCP for 16 weeks improved HR-QoL, mood symptoms, and anxiety symptoms in women with PCOS (87). Unlike other studies, the OWL-PCOS study included women with a diagnosis of PCOS and comorbid affective disorder. The prevalence of depression (which is based on the Primary Care Evaluation of Mental Disorders [PRIME-MD] score and/or use of antidepressant medication) decreased from 13.3% to 4.4% in the OCP group, and the prevalence of clinically significant anxiety (which is also based on the PRIME-MD score and/or use of medication) decreased from 6.7% to 2.2%. Thus, low-dose OCPs may be beneficial not only for metabolic outcomes in PCOS but also for mood symptoms.

Finally, insulin-sensitizing agents such as metformin have been shown to improve psychiatric symptoms in PCOS. Metformin significantly improved QoL, depressive symptoms, and/or anxiety symptoms in multiple studies (88, 89). Participants who were taking metformin had 70% lower odds of having major depressive disorder on the basis of their scores on the nine-item Patient Health Questionnaire than participants treated with lifestyle modifications only, although metformin had no significant impact on anxiety symptoms (90). A survey study found that, before metformin treatment, 92% of participants reported mood swings, which were reduced to 64% after metformin treatment (91). Pioglitazone outperformed metformin in reducing depression and anxiety scores among individuals with PCOS independent of its insulin-sensitizing and androgen-reducing effects (92, 93). Notably, the reductions in psychiatric symptoms observed in the pioglitazone group were associated with reductions in inflammatory markers, supporting the hypothesis that the psychiatric symptoms observed in women with PCOS may be related to a state of chronic inflammation. Regardless of whether psychiatric symptoms in PCOS improve secondary to physical symptom amelioration with insulin-sensitizing agents or more specific biological pathways in need of further investigation, these medications show benefit for mood symptoms in PCOS.