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Exp Clin Endocrinol Diabetes 2025; 133(02): 105-107
DOI: 10.1055/a-2502-8913
Letter to the Editor

Anxiety and Depression in Polycystic Ovary Syndrome: An Analysis Using the Hospital Anxiety and Depression Scale (HADS) in Women from a Low-Income Country

Daiane O. Simão
1   Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (Ringgold ID: RIN28114)
,
Aline Vanessa M. P. Santos
1   Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (Ringgold ID: RIN28114)
,
Vitória S. Vieira
1   Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (Ringgold ID: RIN28114)
,
Fernando M. Reis
1   Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (Ringgold ID: RIN28114)
,
Ana Lúcia Cândido
1   Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (Ringgold ID: RIN28114)
,
Fabio V. Comim 
1   Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (Ringgold ID: RIN28114)
,
Jéssica A. G. Tosatti
1   Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (Ringgold ID: RIN28114)
,
Karina B. Gomes 
1   Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (Ringgold ID: RIN28114)
2   Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (Ringgold ID: RIN28114)
› Author Affiliations
Funding Conselho Nacional de Desenvolvimento Científico e Tecnológico | Coordenação de Aperfeiçoamento de Pessoal de Nível Superior
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Polycystic ovary syndrome (PCOS) is a complex disease and the most common endocrine condition that affects women of reproductive age. Its prevalence ranges from 5% to 20%, characterized by hyperandrogenism, menstrual irregularities, and the presence of polycystic and dysfunctional ovaries [1] [2] [3] [4] [5] [6].

Women with PCOS often suffer from a variety of psychiatric disorders [7]. PCOS is associated with a greater likelihood of developing anxiety and depression, with moderate/severe symptoms, compromising the success of clinical treatment [8] [9]. The relationship between these psychiatric disorders and PCOS is not clear, but it is bidirectional and complex, resulting from interactions between sociocultural, family, individual factors, and the syndrome itself [7] [10].

The Hospital Anxiety and Depression Scale (HADS) is a screening instrument validated in Portuguese and widely used in clinical context, as it is a simple, objective and effective method for identifying and monitoring the presence and severity of possible or probable cases of anxiety and depression [9]. It contains 14 items divided into subscale A (anxiety) and subscale D (depression) that are scored separately or by the sum of A and D. The higher the score, the greater the level of anxiety and/or depression. For each item, a 4-point response scale is used, ranging from 0 – “absence of symptoms” to 3 – “maximum symptoms”. A score of 0 to 7 indicates no anxiety and/or depression, a score of 8 to 10 indicates mild anxiety and/or depression, a score of 11 to 14 indicates moderate anxiety and/or depression, and a score of 15 to 21 indicates anxiety and/or severe depression. For each subscale (A and D), 0 to 21 points can be obtained [8] [9] [10].

The average per capita income of Brazilians is US$318, and Brazil ranks 89th in the Human Development Index, according to the United Nations Organization [11] [12]. Low-income countries, such as Brazil, present a higher risk of psychiatric diseases due to less favorable socioeconomic conditions, making it not possible to extrapolate epidemiological data from PCOS patients who live in developed countries. Therefore, the objective of this study was to compare the HADS between Brazilian women with PCOS and a healthy control group, and its relationship with anthropometric variables.

This case-control study was approved by the Research Ethics Committee of the Federal University of Minas Gerais (n. CAAE 05398918.2.0000.5149). Data were collected after consent and signing of the Informed Consent Form. This study was carried out from February to December 2023, with 47 women with PCOS, in which the diagnosis was established according to the criteria by the European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine PCOS Consensus Workshop Group (Rotterdam) [13]. The control group included 47 healthy women, who presented regular ovulatory cycles, normal androgen levels, and no hirsutism. Women over 40 years of age, pregnant or undergoing nutritional monitoring were excluded.

The groups were assessed by a trained nutritionist, who applied the HADS to both groups, measuring weight and height on a calibrated scale in both groups for body mass index (BMI) determination. Arm (AC), waist (WC), and hip circumferences (HC) were measured with an inelastic tape only in the PCOS group. Statistical analyses were performed using SPSS version 21.0 software. Normality was assessed using the Shapiro-Wilk test. Data were expressed as median and interquartile range (IQ: third quartile – first quartile). The Spearman test was performed to evaluate the correlation between the variables and chi-square to compare frequencies. The significance level adopted was 5%.

The PCOS and control groups had similar ages and income, while the PCOS group had, as expected, higher BMI values. The majority of women in both groups self-declared as mixed race ([Table 1]).

Table 1 Characteristics of polycystic ovary syndrome and control groups.

Variable

PCOS (n=47)

Control (n=47)

p-value

Age (years)

33 (7)

30 (10)

0.081

BMI (kg/m 2 )

31 (10)

24 (9)

0.001* 

Income (R$)

2.640,00 (1.905,00)

3.000,00 (3.290,50)

0.076

Race

 Caucasian

21.4%

33.3%

0.555

 Mixed

52.4%

55.6%

 Black

26.2%

11.1%

PCOS: polycystic ovary syndrome; BMI: body mass index; Mann-Whitney test, expressed as median and IQ. Chi-square test, expressed as frequency. R$1 ~ US$0.18. *Significance: p<0.05.

A higher score on the depression subscale was observed in women with PCOS compared to the control group (median 7.0 vs. 5.0, p=0.013). The PCOS group also presented a higher total score (median 16.0 [severe] vs. 13.0 [moderate]) and greater severity of anxiety (median 11.0 vs. 8.0) compared to the control group, although with only a tendency to significance (p=0.053) ([Table 2]).

Table 2 Assessment of anxiety and depression using the HADS in the polycystic ovary syndrome and control groups.

Variable

PCOS (n=47)

Control (n=47)

p-valor

Subscale A

11.0 (9.0)

8.0 (6.0)

0.169

Subscale D

7.0 (6.5)

5.0 (5.0)

0.013* 

TOTAL

16.0 (15.5)

13.0 (11.0)

0.053

HADS: Hospital Anxiety and Depression Scale; PCOS: polycystic ovary syndrome; A: anxiety, D: depression. Median and IQ. Mann-Whitney test.  *Significance: p<0.05.

No correlation between HADS and BMI in the control group was observed (p=0.900). In the PCOS group, the depression score showed a significant correlation with BMI (r=0.352, p=0.026), HC (r=0.360, p=0.022), and WC (r=0.329, p=0.038).

Depression can be present in more than 60% of women with PCOS [12]. These women can be up to eight times more likely to develop depression than healthy controls and have a four times greater chance of experiencing moderate to severe depressive symptoms. Although the mechanisms of depression in PCOS are not yet fully understood, changes in neurotransmitters and low-grade inflammation added to the body image concerns related to hyperandrogenism and overweight play a significant role [14] [15] [16]. This scenario may be worsened by the limited socioeconomic conditions faced by these women living in developing countries.

Chronic exposure to stressors, such as comorbidities associated with the syndrome (obesity, insulin resistance, and dyslipidemia) and lifestyle factors (poor diet, sedentary lifestyle, and increased chronic stress), promotes a state of chronic low-grade inflammation in these patients. Chronic exposure to inflammatory cytokines impairs neuronal functions, affecting signaling, synthesis, reuptake, and release of neurotransmitters, promoting depressive mood, sleep disorders, and feelings of worthlessness, as well as more severe depressive symptoms [17] [18].

Neuroendocrine dysfunction in the hypothalamic-pituitary-gonadal axis in PCOS may also contribute to depression. The severity of hyperandrogenism is associated with greater mental stress in PCOS [19]. Chronic stress associated with PCOS complications, in turn, contributes to the release of cortisol and continuous hyperstimulation of the hypothalamic-pituitary-gonadal axis, forming a vicious cycle that can also contribute to depression [14].

Additionally, other common aspects of PCOS, such as infertility, excessive hair growth in areas generally associated with men, weight and body fat gain, acne, and alopecia, can contribute to anxiety, depression, and body image dissatisfaction in women with PCOS. The coexistence of anxiety and depression in individuals with PCOS can increase the suffering involved in the disease and interfere with the success of treatment [9], by reducing the quality of life and sexual satisfaction of these women [20].



Publication History

Article published online:
22 January 2025

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