Women with depression and polycystic ovary syndrome (PCOS) can be trapped in a vicious cycle of hormonal dysregulation. Treating these patients appropriately—with or without antidepressants—requires an understanding of their underlying metabolic disorder.
This article presents a case1 that exemplifies the association between depression and PCOS (Box 1).2-4 Based on our research and clinical experience, we offer recommendations to help you manage depression in patients with PCOS.
CHRONIC DEPRESSION WITH AMENORRHEA
Ms. K, age 30, presented for psychiatric evaluation of treatment-resistant recurrent major depression. Her symptoms included sad mood, sleep disturbance, decreased energy, anhedonia, poor concentration, and feelings of guilt and worthlessness. Her score of 28 on the Hamilton Rating Scale for Depression (HAM-D-21) indicated severe depression.
Polycystic ovary syndrome (PCOS) is the most common cause of menstrual disturbance in women of reproductive age, affecting approximately 5% of U.S. women.1 Clinically, it is the association of hyperandrogenism with chronic anovulation, without specific underlying adrenal or pituitary gland disease.2
PCOS has been shown to be associated with depression, though little research has been done in this area. We conducted a pilot study (the first, to our knowledge) to examine the rate of depression among women with documented PCOS and to correlate Center for Epidemiological Studies Depression Scale (CES-D) scores indicative of depression with clinical and biochemical markers of PCOS. We found an increased prevalence of depression in women with PCOS and an association between depression, insulin resistance, and body mass index. Specifically, among 32 women with documented PCOS,3 16 (50%) had CES-D scores indicating depression.
This was Ms. K’s third episode of major depression, with the first two occurring at ages 24 and 26. She reported similar symptoms each time. Previous psychiatrists had tried a variety of antidepressants with no therapeutic benefit before she responded to citalopram, 40 mg/d, at age 27. With this selective serotonin reuptake inhibitor, her depressive symptoms resolved for >1 year, except for mild irritability and low mood the week before menses.
Her depressive symptoms returned, however, and her previous psychiatrist treated her for approximately 13 months with extended-release venlafaxine, 225 mg/d. When she remained depressed, she was referred to our clinic for evaluation. Based on her history, we could not determine whether she had become euthymic at age 27 or her symptoms had improved but still met criteria for a major depressive episode.
Ms. K reported having PCOS symptoms from age 19. These included amenorrhea since menarche, hirsutism, hair loss, alopecia, central fat distribution characteristic of PCOS, and male-pattern hair growth on her abdomen and thighs. She was not obese—with a body mass index (BMI) of approximately 25—but had gained 10 to 15 lbs while taking venlafaxine.
Ms. K had never been treated for PCOS but reported that her desire to become pregnant made her more concerned about her symptoms and possible infertility.
Diagnosis. PCOS is usually diagnosed using endocrinologic, clinical, and ultrasonographic criteria (Table 1). Obesity is not a presenting symptom in all women with PCOS. As with Ms. K, about 50% of patients have normal BMI.
Causes of depression in PCOS. Depressed mood in PCOS may be both physiologic and psychological:
- Hypothalamic, pituitary, and other end-organ system dysregulation occurs in both PCOS and affective disorders, which share clinical and biochemical markers including insulin resistance, obesity, and hyperandrogenism.
- PCOS’ clinical sequelae—hirsutism, acne, obesity, hormonal disturbances, fear of infertility, and psychological distress—may damage their self-esteem and female identity.
PCOS’ physical symptoms alone apparently do not account for patients’ worsened mood states. Weiner et al5 found that women with PCOS and free testosterone (FT) of 10 to 26 pg/mL (just above normal range) were more depressed than women without PCOS (FT <10 pg/mL) and women with PCOS and FT >26 pg/mL. Women with PCOS with the lower and higher FT levels had similar demographic profiles, but those with the highest FT levels were not the most depressed.
Similarly, in a study of 32 women with PCOS, we found no association between depression and other possibly distressing PCOS symptoms, including hirsutism, irregular menses, acne, or alopecia.4
Testosterone and mood disorders. Women such as Ms. K with hyperandrogenic syndromes are at increased risk for mood disorders.6 Many metabolic changes associated with PCOS—insulin resistance, obesity, and hyperandrogenism—are also described in patients with affective disorders. Our investigation of reproductive status in women with bipolar disorder found no clinical or biochemical evidence of PCOS with mood-stabilizer treatment. We did find that menstrual disturbances were common, however, and sometimes preceded bipolar disorder onset.7
Insulin resistance and depression. Others have linked insulin resistance and depression;8 depression has been shown to be associated with impaired insulin sensitivity and hyperinsulinemia.9 Depressed persons also tend to eat more sweets, drink more alcohol, exercise less, and sleep fewer hours than the nondepressed—all of which contribute to insulin sensitivity and insulin resistance.10