Polycystic ovary syndrome (PCOS) has historically been considered a reproductive hormone issue. However, females with PCOS have elevated risks of metabolic and cardiovascular health issues. In fact, insulin resistance is an underlying cause of PCOS for the vast majority of females with the syndrome.

I’m currently reading Dr. Christopher Palmer’s book Brain Energy. Admittedly, I haven’t gotten too far into the book, but from hearing him on several podcast episodes, I know that his main theory is that metabolic issues are an underlying cause of most, if not all mental illness.

Given the prevalence of metabolic dysfunction among females with PCOS, if Dr. Palmer’s hypothesis is true, it is unsurprising that females with PCOS would also experience increased rates of things like depression and anxiety. This article explores some of the research on this association as well as some of the research on tools that can improve mental health indicators for PCOS.

Of course, if you are struggling with any mental health challenge, please go see your healthcare provider! But you might also consider how your metabolic health, nutrition, and lifestyle are playing a role. And I’d love to help you with this, if you’re in need of nutrition and lifestyle coaching!

Are females with PCOS more likely to experience Depression, anxiety, and other mental illnesses than females without PCOS?

There are several studies that make use of large medical records databases to determine if rates of mental illness are higher among females with PCOS compared to females without PCOS. I’m going to summarize these findings and then dig a bit deeper into one study that uses slightly more sophisticated methods.

Mental health challenges are an often over-looked component of polycystic ovary syndrome (PCOS).

One of these studies (Cesta et al. 2016) combined several patient databases in Sweden to identify medical records of 26,413 females with PCOS. They excluded patients with illnesses that cause symptoms similar to PCOS to avoid possible misdiagnosis, as well as patients who were diagnosed prior to the age of 13 without additional diagnostics run later in life due to the challenges in correctly diagnosing PCOS at an early age. After these exclusions, they were left with 24,385 females with PCOS.

To construct a control population of females with PCOS, they randomly selected 10 females with the same sex, birth year, and county of residence from the general population without a PCOS diagnosis. They then compared rates of various mental illnesses among those females with a PCOS diagnosis and comparable females without the diagnosis. The comparisons are included in the table below.

This study found that females with PCOS were about 1.5 times as likely to suffer from depression or anxiety, twice as likely to be on the autism spectrum, and about 1.2 times as likely to have ADHD than females without PCOS.

In a similar study, Damone et al. (2018) used data from the Australian Longitudinal Study on Women’s Health which began in 1996. This study makes use of data from participants born between 1973 and 1978, who would have been 18 - 23 years old at the time of the first survey conducted in 1996. However, the study uses responses to the survey completed in 2006 (the 4th round of the survey). A total of 8,612 survey respondents answered the question regarding PCOS status. 478 females indicated that they had been diagnosed with PCOS, while the remaining 8,134 reported not having a PCOS diagnosis. The survey also included questions commonly used to diagnose depression and anxiety. Based on responses to these questions, respondents were categorized as either meeting the criteria for depression or anxiety or not. The comparison of these rates is also included in the table below.

It should be noted that the percent meeting the criteria for anxiety or depression based on the survey question responses is substantially higher than the percent reported as having received a diagnosis among respondents in the study by Cesta et al. This suggests to me that many people are struggling with mental illnesses but not seeking medical attention for these illnesses.

Despite having higher rates of anxiety and depression in their sample, like the previous study, they found that females with PCOS were almost 1.5 times as likely to meet the criteria for depression. In terms of anxiety, this study found that females with PCOS were only about 1.25 times as likely to have anxiety than females without PCOS.

Hart and Doherty (2015) also make use of a dataset from Australia, although they use several linked health databases, including one that contains hospitalization records for all public and private hospitals in Western Australia. This study made use of records ranging from 1997 to 2011, and they were able to identify complete records for 2,566 females with PCOS. Each of these females were then matched to 10 females without PCOS, providing a control group of 25,660 females without PCOS. This study compares rates of a wide variety of health issues among females with and without PCOS, but I will just include the comparisons for mental illnesses, as can be found in the table below.

This study finds that females with PCOS are more than twice as likely to be diagnosed with anxiety or depression. It is unclear why this study finds a larger difference in anxiety and depression rates making use of hospitalization data specifically instead of general medical records. It seems like there is somehow greater contrast in mental health among females with PCOS who are hospitalized compared to those without PCOS who are hospitalized, which I think warrants further study.

The last study (Karjula et al. 2017) in this category made use of the Northern Finland Birth Cohort 1966, a dataset that includes all people in Finland born in 1996. This cohort includes 5889 females who have been followed for 46 years. They were asked about two of the primary symptoms of PCOS: having oligomenorrhea (menstrual cycles lasting longer than 35 days) and having excessive facial and/or body hair growth. Females who reported both of these symptoms were classified as having PCOS by the researchers. Given the use of these two questions to classify PCOS, the researchers had to exclude all females on hormonal birth control which would mask signs of oligomenorrhea. Many females with PCOS take hormonal birth control to manage irregular periods and symptoms, so this study likely excludes many females with PCOS. At the same time, the use of these two questions to diagnose the remaining females with PCOS or not likely yields a higher percent designated as having PCOS than the previous studies that relied on formal diagnosis of PCOS. Nonetheless, after the exclusions and this classification process, the researchers had a sample of 86 females with PCOS and 1628 females without PCOS. This study reports anxiety and depression rates at both ages 31 and 46. I am choosing to report their data for age 31 only, due to the potential compounding effects of perimenopause among females at age 46.

They find that females with PCOS are about 1.5 times as likely to have been diagnosed with depression and almost twice as likely to have been diagnosed with anxiety than females without PCOS.

The table below compares rates across females with and without POCS for all studies. We can see that females with PCOS have higher rates of anxiety, depression, and almost every other mental health disorder considered.

A table summarizing rates of mental illness among females with and without PCOS — A summary of four studies comparing rates of mental illness among females with and without polycystic ovary syndrome (PCOS). Females with PCOS are more likely to have depression, anxiety, and a wide variety of other mental illnesses than females without PCOS. “No significant difference” means that any differences were not statistically significantly different from zero. Sources: Cesta et al, 2016, Damone et al. 2019, Hart and Doherty 2015, Karjula et al. 2017.

PCOS and Mental ILlness- Correlation vs. causation

The studies described above only report correlations between PCOS and mental illness. They cannot distinguish between scenarios where PCOS causes mental illness, where mental illness causes PCOS, or where some other underlying factor causes both PCOS and mental illness.

A study by Berni et al. 2018 used a slightly different methodology that helps to tease out correlation vs. causation a bit. This study used a database of more than 11 million patients from 674 primary care practices in the United Kingdom. Like previous studies, they identified females with PCOS (16,986 females) and then randomly selected matching females without PCOS. This study used two sets of controls. The first control group matched their PCOS counterparts based on age, BMI, and primary-care practice. A second set of controls was created that matched their PCOS counterparts based on the previous criteria as well as on prior history of any particular mental health disorders. I’m going to focus on their results for this second control group.

Unlike previous studies that do not distinguish the timing of the PCOS diagnosis vs. mental illness diagnosis, this study restricts mental illness diagnoses to those that occur after the PCOS diagnosis. This helps to show that mental illness is not causing PCOS. It does not, however, distinguish between the other two possibilities: PCOS causes mental illness or that there is some underlying factor that causes both PCOS and mental illness.

Like the previous study, this one still finds higher rates of mental illness among females with PCOS than among females without PCOS. Females with PCOS are about 1.5 times as likely to be diagnosed with depression, about 1.7 times as likely to be diagnosed with anxiety, and almost twice as likely to be diagnosed with an eating disorder compared to similar females without PCOS.

A comparison of the rates of mental illnesses among females with polycystic ovary syndrome (PCOS) and those without PCOS. “No statistically significant difference” means that the differences found were not statistically significantly different than zero. Source: Berni et al. 2018.

why is pcos associated with increased rates of depression, anxiety, and other mental health challenges?

Many hypothesize that the symptoms of PCOS (acne, weight gain, excess facial and body hair, male pattern baldness, and fertility challenges) contribute to mental health challenges among females with PCOS, and this hypothesis does make sense. These symptoms are distressing and would challenge the mental health of most people.

Dr. Palmer, however, suggests that the metabolic factors underlying PCOS also underlie mental health challenges, and this common link is the actual issue.

If this is true, then addressing insulin resistance in females with PCOS should help both their PCOS symptoms as well as mental health challenges.

What can we do to improve mental health if we have PCOS?

Like a lot of topics relevant to those with PCOS, the literature on interventions for mental health among females with PCOS is sparse. However, I found one study with promising results, and I’ll share it here.

In this study, researchers recruited females with PCOS between the ages of 18 and 45, with BMIs between 25 and 50 (overweight to obese) who had been exercising at moderate intensity for less than 150 minutes per week or at high intensity for less than 75 minutes per week. Participants taking medications for anxiety or depression were not excluded from the study.

All participants were randomly assigned to one of two interventions:

High-intensity interval training group, which did the following each week:
- 2 sessions: 12 x 1 minute intervals at 90 - 100% max heart rate with 1 minute of active recovery between sprinting intervals
- 1 session: 8 x 4 minute intervals at 90 - 95% max heart rate with 2 minutes of active recovery between intervals.
Moderate-intensity cardiovascular training group, which did the following each week:
- 3 sessions: 45 minutes each at 60 - 75% max heart rate.

Both groups performed their sessions on stationary bicycles and followed their training plans for 12 weeks.

All participants completed a questionnaire before and after the exercise intervention which included questions commonly used to diagnose individuals with depression and anxiety. They also included questions used to develop a perceived stress score.

On average, participants experienced decreases in all three scores, indicating improved mental health from the addition of their exercise program. There were no statistically significant differences in the changes experienced between groups in terms of depression scores or stress score. The HIIT group experienced a larger reduction (a 51% reduction) in their anxiety score compared to the MICT group (a 40% reduction).

While HIIT demonstrated an edge over MICT in terms of anxiety, this study suggests that either option can improve mental health among females with PCOS, and it only took 3 sessions a week to see substantial improvements in all measures of mental health.

A table comparing the effects of HIIT and MICT on anxiety, depression, and stress score among females with polycystic ovary syndrome (PCOS) — A comparison of the effects of a 12-week exercise intervention with either high-intensity interval training (HIIT) or moderate-intensity cardiovascular training (MICT) on depression, anxiety, and stress scores among females with polycystic ovary syndrome (PCOS). “No statistically significant difference” means that the differences found were not statistically significantly different than zero. Source: Patten et al. 2023

take home points

Several studies making use of large datasets demonstrate that rates of depression, anxiety, and other mental health disorders are higher among females with PCOS than females without PCOS, even controlling for factors like age, weight, previous history of mental illness, and location.

Just three exercise sessions a week at either moderate intensity or high intensity can improve measures of mental health. High-intensity interval training may yield larger improvements in anxiety than moderate intensity training, but both are beneficial.

references

Berni TR, Morgan CL, Berni ER, and Rees DA. 2018. Polycystic Ovary Syndrome Is Associated With Adverse Mental Health and Neurodevelopmental Outcomes. Journal of Clinical Endocrinology and Metabolism, 103(6):2116–2125. doi: 10.1210/jc.2017-02667.

Cesta CE, Månsson M, Palma C, Lichtenstein P, Iliadou AN, and Landén M. 2016. Polycystic Ovary Syndrome and Psychiatric Disorders: Co-morbidity and Heritability in a Nationwide Swedish Cohort. Psychoneuroendocrinology, 73:196–203 http://dx.doi.org/10.1016/j.psyneuen.2016.08.005

Damone AL, Joham AE, Loxton D, Earnest A, Teede HJ, and Moran LJ. 2019. Depression, Anxiety and Perceived Stress in Women with and without PCOS: A Community-based Study. Psychological Medicine, 49:1510–1520. https://doi.org/ 10.1017/S0033291718002076.

Hart R and Doherty DA. 2015. The Potential Implications of a PCOS Diagnosis on a Woman’s Long-Term Health Using Data Linkage. Journal of Clinical Endocrinology and Metabolism, 100(3):911–919. doi: 10.1210/jc.2014-3886

Karjula S, Morin-Papunen L, Auvinen J, Ruokonen A, Puukka K, Franks S, Jarvelin M, Tapanainen JS, Jokelainen J, Miettunen J, and Piltonen TT. 2017. Psychological Distress Is More Prevalent in Fertile Age and Premenopausal Women With PCOS Symptoms: 15-Year Follow-Up. Journal of Clinical Endocrinology and Metabolism, 102(6):1861–1869 doi: 10.1210/jc.2016-3863

Patten RK, McIlvenna LC, Moreno-Asso A, Polman R, Teede HJ, and Stepto NK. 2023. Efficacy of high-intensity interval training for improving mental health and health-related quality of life in women with polycystic ovary syndrome. Scientific Reports, 13:3025. https://doi.org/10.1038/s41598-023-29503-1