J. Obstet. Gynaecol. Res. 2015

doi:10.1111/jog.12696

Psychiatric comorbidity in women with polycystic ovary syndrome Bilge Burçak Annagür , Özlem Seçilmiş Kerimoglu , Aybike Tazegül , Şule Gündüz and 2 Berat Berrin Gençoglu 1

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Department of Psychiatry, Faculty of Medicine, Selçuk University and 2Department of Obstetrics and Gynecology, Faculty of Medicine, Selçuk University, Konya, Turkey

Abstract Aim: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder that women experience during their reproductive years and is associated with many psychiatric disorders. This study sought to determine the existence of psychiatric disorders in women with untreated PCOS. Another objective of the study was to examine whether an association exists between psychiatric disorders, insulin resistance, and body mass index. Material and Methods: Women who met the Rotterdam criteria for PCOS (n = 88) were included. Structured Clinical Interviews for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edn were conducted. After the psychiatric evaluations, blood samples were obtained from the participants. Results: Prevalence for all comorbid psychiatric disorders was 50% (n = 44). The most common psychiatric disorder was major depression (33%), followed by generalized anxiety disorder (13.6%) and binge-eating disorder (6.8%). No significant difference in body mass index and insulin resistance index scores was found between women with and without psychiatric disorders (P > 0.05 for both comparisons). Conclusion: A considerable number of women with PCOS experience a psychiatric disorder during their lifetime. Clinicians should be aware that women with PCOS are at a high risk for major depression, generalized anxiety disorder, and binge-eating disorder. Key words: anxiety, depression, hyperandrogenism, polycystic ovary syndrome, psychiatric comorbidity.

Introduction Polycystic ovary syndrome (PCOS) is the most common endocrine disorder that women experience during their reproductive years, affecting 5–10% of all women.1 PCOS is characterized by androgen hypersecretion, insulin resistance, chronic anovulation, and morphological abnormalities of the ovaries. Clinical manifestations include hirsutism, acne, alopecia, menstrual irregularities, obesity, and infertility.2 Obesity and resistance to insulin play a significant role in the pathogenesis of PCOS. Obesity increases the risk of insulin resistance, although insulin resistance can also occur in the absence of obesity.2,3 The resulting state of

hyperinsulinemia stimulates the production of ovarian androgen and hypophysical luteinizing hormone.4 Approximately two-thirds of women with PCOS are overweight or obese, and obesity has been implicated in depression in women for the general population.5–8 Additionally, several researchers have suggested an association between insulin resistance and depression.9–11 Although some authors have proposed that insulin resistance may have a pathological relation in depression and PCOS,12 the specific mechanisms underlying the association between depression and insulin resistance in PCOS remain unknown. Pastore et al. suggest that there is a strong positive association between depression symptom severity and

Received: April 29 2014. Accepted: January 13 2015. Reprint request to: Associate Professor Bilge Burçak Annagür, Selçuk Üniversitesi, Selçuklu Tıp Fakültesi, Psikiyatri AD, 42075 Selçuklu-Konya, Turkey. Email: [email protected]

© 2015 The Authors Journal of Obstetrics and Gynaecology Research © 2015 Japan Society of Obstetrics and Gynecology

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dissatisfaction with their physical appearance and physical conditioning in women with PCOS.13 Niet et al. reported that women with PCOS had lower levels of self-esteem, and a greater fear of negative appearance evaluation.14 In the mentioned study, it was determined that clinical characteristics, such as hyperandrogenism and acne, were associated with poorer body satisfaction, whereas hirsutism and body mass index (BMI) unfavorably affect self-esteem, body satisfaction, and fear of negative appearance. Numerous studies have evaluated the relation between PCOS and psychiatric disorders; however, most have evaluated psychiatric symptoms based on self-report measures.13–15 Several studies have established that women with PCOS are more likely to experience depressive symptoms compared to women without PCOS.15–17 Few studies based on structured clinical interviews have been conducted and have yielded different results.8,18,19 For these reasons, we sought to use a structured clinical interview to assess the presence of psychiatric disorders in women with untreated PCOS. Another objective of our study was to examine whether an association between psychiatric disorders, insulin resistance, and BMI exists.

recorded in the outpatient clinic of gynecology and obstetrics. Then, the women were referred to the psychiatry department where psychiatric interviews were conducted using the Structured Clinical Interview (SCID-I) for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edn (DSM-IV).21,22 SCID-I is a semi-structured diagnostic interview to diagnose DSM-IV disorders. It has shown high reliability in severe psychiatric disorders and is used as a standard interview in clinical studies to confirm the diagnosis.22 After the psychiatric evaluations, blood samples were obtained from the participants.

Measures The clinical and biochemical characteristics collected from the participants included age, height, weight, and fasting morning serum levels of insulin and glucose. BMI was calculated as kg/m2. Insulin resistance was calculated using the homeostasis model assessment insulin resistance index (fasting insulin × fasting glucose / 405) (μIU/mL).23 All venous blood samples were obtained in the morning between 08.00 and 09.00 hours after an overnight fast. Insulin analysis was performed using the electrochemiluminescent method with original reagents on E170 Modular Analytics (Roche Diagnostics).

Methods Statistical analysis

Setting and sample This study was conducted among women with untreated PCOS who were admitted to the Outpatient Clinic of Gynecology and Obstetrics at the Faculty of Medicine of Selçuk University between March and September 2011. PCOS was defined according to criteria established by the Rotterdam PCOS Consensus Workshop group, as sponsored by the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine.20 Inclusion criteria were as follows: women 18 years or older who had an ability to communicate and to read and write in Turkish. The exclusion criteria were as follows: a history of neurological disease and concomitant severe medical illnesses (e.g., diabetes mellitus, severe thyroid disease). A total of 88 consecutive women met the criteria and were included in the study.

Procedures The objectives and procedures of the study were explained, and written informed consent was obtained from all participants. The study was approved by the ethical committee of the Faculty of Medicine, Selçuk University. Women with PCOS (n = 88) were included and all met the Rotterdam criteria for PCOS. The sociodemographic characteristics of the participants were

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The data were analyzed using SPSS 16.0 for Windows. Descriptive statistical analyses were conducted on the demographic and clinical characteristics of the participants. The χ 2-test and Fisher’s exact test were used to analyze categorical variables, and the t-test was used for the comparison of parametric continuous variables. All significant levels were two-tailed and set at the 0.05 level.

Results The mean (±SD) age of the total sample (n = 88) was 22.26 years (SD = 3.55). Most of the participants were university students (75%), single (88.6%), and unemployed (90.9%). Table 1 presents the lifetime and the current prevalence rates for all psychiatric disorders among the participants. The lifetime prevalence rate for all comorbid psychiatric disorders in the sample was 50% (n = 44). The most common psychiatric disorder was major depressive disorder (MDD) (33%), followed by generalized anxiety disorder (GAD) (13.6%) and binge-eating disorder (6.8%). Other psychiatric diagnoses included any mood disorder (35%), bipolar disorder-II (2.3%), any anxiety disorder (19%), social phobia (2.3%), panic

© 2015 The Authors Journal of Obstetrics and Gynaecology Research © 2015 Japan Society of Obstetrics and Gynecology

Psychiatric comorbidity in PCOS

Table 1 Lifetime and current prevalence of psychiatric disorders among women with PCOS (n = 88) Psychiatric disorders Mood disorders Major depression Bipolar disorder (type I) Dysthymia Anxiety disorders Generalized anxiety disorder Social phobia Panic disorder Obsessive–compulsive disorder Post-traumatic stress disorder Eating disorders Anorexia nervosa Bulimia nervosa Binge-eating disorder

Lifetime

Current

n

%

n

%

31 29 2

35 33 2.3

26 24 2

29.5 27.2 2.3

0 17 12

0 19 13.6

0 14 12

0 15.9 13.6

2 2 1

2.3 2.3 1.1

2 0 0

2.3 0 0

0

0

0

0

8 0 2 6

9 0 2.3 6.8

8 0 2 6

9 0 2.3 6.8

disorder (2.3%), obsessive–compulsive disorder (1.1%), any eating disorder (9%), and bulimia nervosa (2.3%). Among the patients with PCOS and a psychiatric diagnosis, 12 (13.6%) met the criteria for at least two psychiatric disorders according to SCID-I. In these women, eight out of 12 had MDD and GAD; and four out of 12 had MDD and binge-eating disorder. All participants were separated into two groups: those with lifetime psychiatric diagnosis (PD) (n = 44), and those without any psychiatric disorders (no diagnosis [ND]). The sociodemographic and clinical characteristics of the two groups are presented in Table 2. There was no statistically significant difference between the sociodemographic characteristics of PCOS patients with and without psychiatric disorders regarding age, education level, or marital status. In addition, no significant difference was found between the two groups in terms of BMI or insulin resistance index scores (P > 0.05 for both comparisons).

Discussion There was a high prevalence of psychiatric comorbidity among women with PCOS (50%), and major depression was the most common psychiatric disorder in this study (33%). Generalized anxiety disorder was the second most frequent diagnosis (13.6%). These results are consistent with previous studies that have reported elevated

Table 2 Sociodemographic and clinical characteristics of polycystic ovary syndrome patients with and without psychiatric disorders Features

PD (n = 44)

Age† Education‡ Elementary Secondary Higher education Marital status‡ Married Single Employment‡ Employed Unemployed BMI† Insulin resistance†

ND

P

(n = 44)

22 ± 3.5

22.2 ± 3.5

3 (6.8) 10 (22.7) 31 (70.5)

3 (6.8) 6 (13.6) 35 (79.5)

5 (11.4) 39 (88.6)

4 (9.1) 40 (90.9)

2 (4.5) 42 (95.5) 25 ± 6.4 2.78 ± 2.4

6 (13.6) 38 (86.4) 23 ± 4.3 2.57 ± 1.8

0.735 0.537

0.559

0.133

0.125 0.646

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†Student’s t-test. ‡χ -test. BMI, body mass index; ND, not diagnosed (patients without any psychiatric disorders); PD, patients with lifetime psychiatric diagnosis.

rates of psychiatric disorders in women with PCOS. In the published work, the prevalence of psychiatric disorders in women with PCOS has been reported to range between 57% and 67%.18,19,24 The exact cause for increased risk of psychiatric disorders in women with PCOS remains unclear.12,19,24 Some authors have suggested that women with hyperandrogenic syndromes may be at an increased risk for mood disorders because of an association between elevated androgen levels and depression.12,25,26 Rasgon et al.12 suggested that women receiving oral contraceptives for the treatment of PCOS were less depressed than women not receiving this type of treatment. These results imply a relation between depression and hormonal factors in women with PCOS. Our findings are consistent with previous studies that have found that major depression was the most common psychiatric disorder in women with PCOS.18 Previous studies have noted a positive correlation between BMI and depressive symptoms in women with PCOS.12,19,27 Obesity is common among women with PCOS and also has been linked to depression.8 Furthermore, many studies have reported an association between insulin resistance and depression.9–11 Insulin also affects central serotonin (5-HT) levels.28 Central 5-HT system dysregulation that causes depression might simultaneously affect peripheral insulin sensitivity or vice versa.9 Contrary to previous findings, we found no significant difference in BMI and insulin resistance index among patients with PCOS with and without

© 2015 The Authors Journal of Obstetrics and Gynaecology Research © 2015 Japan Society of Obstetrics and Gynecology

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psychiatric disorders. These differences may be attributed to the previous studies’ participant characteristics. In our study, all of the women were young and newly diagnosed with PCOS. Additionally, the mean BMI of the total sample was

Psychiatric comorbidity in women with polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder that women experience during their reproductive years and is associated with ma...
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