Polycystic ovary syndrome (PCOS) is a prevalent reproductive endocrine disorder affecting approximately 5% to 10% of women of reproductive age in Western populations. The reported prevalence varies widely in India, ranging from 3.7% to 22.5%. PCOS is clinically defined by a constellation of features that may include hyperandrogenism, polycystic ovarian morphology on ultrasonography, and menstrual irregularities such as oligomenorrhea or amenorrhea. These manifestations form the basis of the diagnostic criteria widely adopted in clinical practice.1,2 The underlying pathophysiology of PCOS is multifactorial, with obesity and insulin resistance being prominent contributors. Hyperinsulinemia resulting from insulin resistance promotes excessive ovarian androgen production, primarily via upregulation of the cytochrome P450c17 enzyme complex. Additionally, increased insulin levels stimulate pituitary luteinizing hormone (LH) secretion, further disrupting the hormonal balance. This cascade contributes to the anovulatory cycles and endocrine abnormalities characteristic of PCOS.3,4 Women with PCOS are at an increased risk of developing hypertension, dyslipidemia, and type 2 diabetes mellitus. In addition to these metabolic disturbances, the reproductive manifestations of PCOS such as acne, hirsutism, menstrual irregularities, obesity, and infertility contribute significantly to psychological distress. These factors often lead to heightened levels of anxiety, depression, and impaired sexual functioning, which adversely affect overall psychological well-being and quality of life. Moreover, the prevalence of depression is generally higher in women than in men. It is hypothesized that hormonal fluctuations in ovarian steroids during various phases of the reproductive cycle play a critical role in this gender disparity.5,6 Women with major depression often experience earlier onset, stronger familial predisposition, and poorer social adjustment and quality of life compared to men. Studies suggest that up to 25% of women may meet the criteria for major depressive disorder (MDD) in their lifetime, with a reported 12% prevalence of depressive disorders among obstetric-gynecologic patients. These findings highlight the critical need for early detection of depression in women of reproductive age.7,8 Many chronic illnesses negatively impact mental health, often leading to reduced quality of life and increased depressive symptoms. Among women with PCOS, the prevalence of depression is notably higher and varies widely, ranging from 28% to 64%.9.10 Similarly, anxiety is also common in this population, with reported prevalence rates ranging from 34% to 57%.11,12 The higher prevalence of anxiety and depression in women with PCOS is multifactorial and complex. Several studies suggest that the physical manifestations of the syndrome such as acne, hirsutism, and elevated body mass index contribute significantly to psychological distress. Infertility-related challenges have also been linked to higher rates of depression among affected women.13,14 While some research has reported a possible association between insulin resistance and depressive symptoms, findings remain inconsistent. These overlapping biological, cosmetic, and reproductive concerns collectively contribute to the increased mental health burden observed in this population.15,16 Women with polycystic ovarian syndrome (PCOS) frequently experience anxiety, depression, and reduced quality of life. Although earlier studies have primarily focused on measuring symptom severity, few have utilized standardized diagnostic criteria or comprehensively explored associations between PCOS and psychiatric morbidity within the Indian population. This study aims to determine the prevalence and severity of depression and anxiety using validated diagnostic tools, analyze their association with socio-demographic and clinical factors, and compare the overall quality of life between women with PCOS and healthy controls.

Study Design and Setting A comparative, observational study was conducted over six months in the Department of Obstetrics and Gynaecology at SSG Hospital, Vadodara, Gujarat, India. Ethical clearance was obtained from the Institutional Ethics Committee, and written informed consent was taken from all participants before enrolment. Study Participants The study population consisted of 180 women aged between 18 and 45 years. The study group comprised 90 cases diagnosed with polycystic ovarian syndrome (PCOS) according to the Rotterdam 2004 criteria, which require at least two of the following: oligo- or anovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasonography. The control group included 90 age-matched women with regular menstrual cycles, no clinical or biochemical signs suggestive of PCOS, and no current or past history of psychiatric illness. Inclusion and Exclusion Criteria Women were included if they were between 18 and 45 years of age and provided written informed consent. Those diagnosed with PCOS were included in the case group, while those with no features of PCOS or psychiatric history were included as controls. Women were excluded if they were outside the defined age range, pregnant or lactating, had a known psychiatric disorder, were on psychotropic medication, or had any major chronic illness. Sampling and Sample Size Purposive sampling was employed to recruit participants who met the eligibility criteria. The sample size was determined based on an expected difference in anxiety prevalence between the groups (13.3% in PCOS vs. 2% in controls), with a 95% confidence interval and 80% statistical power, resulting in 90 subjects per group. Data Collection Tools Data were collected using a semi-structured proforma that captured socio-demographic details, clinical history, and menstrual patterns. Psychological morbidity was initially screened using the General Health Questionnaire-28 (GHQ-28), a standardized self-administered tool that identifies non-psychotic psychiatric disorders; a score above four was considered indicative of possible morbidity. Participants meeting the screening threshold were further evaluated using DSM-5 criteria for clinical diagnosis of depression and generalized anxiety disorder. The severity of depression was assessed using the Hamilton Depression Rating Scale (HAM-D), which classifies depression as mild, moderate, severe, or very severe based on the score. Anxiety severity was measured using the Hamilton Anxiety Rating Scale (HAM-A), which categorizes anxiety into mild, moderate, and severe ranges. Quality of life was assessed using the World Health Organization Quality of Life-BREF (WHOQOL-BREF) instrument, which evaluates physical health, psychological well-being, social relationships, and environmental satisfaction through a structured scoring system. Statistical Analysis Statistical analysis was conducted using appropriate software. Continuous variables were expressed as mean and standard deviation and categorical variables as frequencies and percentages. Comparisons between the two groups were performed using the unpaired t-test for continuous variables and the Chi-square test for categorical variables. A p-value less than 0.05 was considered statistically significant.

Table 1: Socio-demographic and Illness-related Features of Study Participants (n=180) Variable PCOS Cases (n=90) Controls (n=90) Age Group 18–30 years 66 (73.3%) 45 (50.0%) 31–40 years 24 (26.7%) 42 (46.7%) >40 years 0 (0.0%) 3 (3.3%) Residence Rural 37 (41.1%) 40 (44.4%) Urban 53 (58.9%) 50 (55.6%) Literacy Level Illiterate 4 (4.4%) 10 (11.1%) Primary education 35 (38.9%) 37 (41.1%) Secondary/Higher Secondary 32 (35.6%) 36 (40.0%) Graduate and above 19 (21.1%) 7 (7.8%) Type of Family Joint family 50 (55.6%) 56 (62.2%) Nuclear family 40 (44.4%) 34 (37.8%) Family History of Psychiatric Illness Present 4 (4.4%) 2 (2.2%) Absent 86 (95.6%) 88 (97.8%) Clinical Features (PCOS-related) Obesity 33 (37.1%) 12 (13.3%) Acne 37 (41.1%) 6 (6.7%) Hirsutism 68 (75.6%) 0 (0.0%) Irregular periods 78 (86.7%) 0 (0.0%) Study Population distribution of PCOS cases were aged 18–30 years (73.3%) compared to controls (50.0%). Educational status differed with more graduates among PCOS cases (21.1%) than controls (7.8%). No differences were observed in residence type, family type, or psychiatric family history. Clinical features such as obesity (37.1% vs. 13.3%), acne (41.1% vs. 6.7%), hirsutism (75.6% vs. 0%), and irregular periods (86.7% vs. 0%) were more prevalent among PCOS cases compared to controls. Table 2: Prevalence of Psychiatric Morbidity and Screening Scores Measure PCOS Cases (n=90) Controls (n=90) p-value GHQ Positive 40 (44.4%) 19 (21.1%) 0.001 GHQ Score (Mean ± SD) 5.20 ± 3.29 3.26 ± 3.11 <0.05 DSM-5 Depression 23 (25.6%) 9 (10.0%) 0.006 DSM-5 Anxiety 15 (16.7%) 5 (5.6%) 0.03 PCOS cases demonstrated a significantly higher rate of GHQ positivity (44.4%) compared to controls (21.1%), with a mean GHQ score of 5.20 ± 3.29, notably higher than controls (3.26 ± 3.11) (p < 0.05). The prevalence of depression and anxiety as per DSM-5 criteria was also greater among PCOS women (25.6% and 16.7%, respectively) versus controls (10.0% and 5.6%), both reaching statistical significance. (Table 2) Table 3: Severity of Depression and Anxiety among Affected Participants Severity PCOS Cases (n=23 for Depression, n=15 for Anxiety) Controls (n=9 for Depression, n=5 for Anxiety) Depression (HAM-D) Mild Depression 15 (65.2%) 6 (66.7%) Moderate Depression 7 (30.4%) 3 (33.3%) Severe Depression 1 (4.3%) 0 (0.0%) Anxiety (HAM-A) Mild Anxiety 8 (53.3%) 3 (60.0%) Moderate Anxiety 6 (40.0%) 2 (40.0%) Severe Anxiety 1 (6.7%) 0 (0.0%) As shown in Table 3, among PCOS cases with depression, most had mild (65.2%) or moderate (30.4%) symptoms, while severe depression was rare (4.3%). In anxiety cases, 53.3% reported mild and 40.0% moderate symptoms, with only one case of severe anxiety. Severity distribution among controls was similar in trend but occurred in fewer individuals. Table 4: WHOQOL-BREF Domain Scores Comparison between Groups Domain PCOS Cases (n=90) Controls (n=90) p-value Physical 66.74 ± 10.79 64.89 ± 10.53 0.245 Psychological 59.47 ± 12.18 62.84 ± 9.96 0.043 Social Relationship 55.88 ± 13.21 62.21 ± 14.49 0.003 Environmental 62.48 ± 9.87 59.93 ± 10.25 0.092 PCOS cases had significantly lower scores in psychological (59.47 ± 12.18 vs. 62.84 ± 9.96; p = 0.043) and social relationship domains (55.88 ± 13.21 vs. 62.21 ± 14.49; p = 0.003). No statistically meaningful differences were found in the physical or environmental domains, indicating that PCOS more prominently affects mental and social well-being. (Table 4)

The present study demonstrates that women with polycystic ovarian syndrome (PCOS) are disproportionately affected by psychological morbidity when compared to age-matched healthy controls. In our research, psychiatric morbidity was significantly more prevalent among PCOS cases, with nearly half of the women screening positive for GHQ-28. These findings resonate with those reported by Chaudhari et al.,17 who found psychological morbidity in over half of PCOS patients, and by Tan et al.,18 who observed comparable trends in Chinese women with PCOS. The prevalence of depression among PCOS participants in our study was 25.6%, which was significantly higher than in the control group. Most of these women had mild to moderate depression, while a small proportion experienced severe symptoms. This distribution is in line with findings by Hollinrake et al.,19 who emphasized a strong association between depression and PCOS independent of obesity and infertility. Similar results have also been documented by previous studies, all of which noted that PCOS contributes to greater emotional vulnerability in affected women.17,18,20. These observations underscore the emotional toll of reproductive challenges, which may heighten vulnerability to mood disturbances among this population. Anxiety was also significantly more frequent in PCOS women than in controls, although overall rates were lower than for depression. Most women with anxiety symptoms had mild to moderate severity, with very few experiencing severe anxiety. These results are supported by previous studies, which each reported that anxiety while present is often under-recognized in women with PCOS.12,21,22 Interestingly, in our research, hirsutism was the only clinical factor significantly associated with anxiety, suggesting that visible symptoms may have a more substantial psychological impact than other metabolic parameters. This is consistent with the observations of Kumarapeli et al.,21 who identified hirsutism as a significant contributor to psychological distress in South Asian women with PCOS. Regarding quality of life, PCOS patients in our study scored significantly lower in the psychological and social relationship domains, indicating a pronounced impact on emotional well-being and interpersonal interactions. However, physical and environmental domain scores did not differ significantly between groups. These findings are supported by earlier studies, which similarly found impaired psychosocial functioning in women with PCOS.12,21,23 In particular, the psychological burden appears to be compounded by factors such as infertility, poor body image, and social stigma—issues frequently encountered by women with this condition. In conclusion, our study reaffirms that PCOS is not only a metabolic and reproductive disorder but also a major contributor to psychological morbidity. The increased rates of depression, anxiety, and compromised quality of life highlight the need for routine mental health screening in this population. Addressing both the physical and psychological dimensions of PCOS through integrated care models can lead to more holistic and effective management strategies for these women.

The present study demonstrates a significant association between polycystic ovarian syndrome (PCOS) and increased psychological morbidity, specifically depression, anxiety, and impaired quality of life. Women with PCOS were found to have significantly higher rates of depression and anxiety compared to healthy controls, with most cases presenting mild to moderate severity. Quality of life was significantly compromised in the psychological and social relationship domains among PCOS participants. These findings emphasize the need for routine psychological evaluation and integrated mental health support in the clinical management of PCOS to address both reproductive and emotional health dimensions comprehensively.

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