Original Study

Polycystic Ovary Syndrome and Depression in New Zealand Adolescents

Stella R. Milsom FRACP 1,2,*, Sasha M. Nair MBChB 3, Cara M. Ogilvie FRACP 1,2, Joanna M. Stewart MSc 4,
Sally N. Merry MD 5
1
Department of Endocrinology, Fertility Associates, Ascot Hospital, Auckland, New Zealand
2
Department of Obstetrics and Gynaecology, National Womens' Hospital, Auckland, New Zealand
3
Diabetes Centre, Greenlane Clinical Centre, Auckland, New Zealand
4
School of Population Health, University of Auckland, Auckland, New Zealand
5
Department of Psychological Medicine, University of Auckland, Auckland, New Zealand

a b s t r a c t
Objective: To determine whether adolescents with polycystic ovary syndrome (PCOS) are more depressed than adolescent girls in the
community and to examine factors associated with depression.
Design: An observational study comparing clinical and community samples.
Setting: Two specialist reproductive endocrine clinics in Auckland, New Zealand.
Participants: 102 girls aged 14-19 presenting for clinical assessment, fullling the Rotterdam consensus for PCOS. The comparison group
was 1349 girls from a school-based survey of New Zealand youth.
Interventions: Clinically signicant depression was identied by the long and short form Reynolds Adolescent Depression Scale. BMI,
androgen levels, oral contraceptive use, objective symptom severity, age, ethnicity, and socioeconomic grouping were recorded.
Main Outcome Measures: Clinically signicant depression in the PCOS and community samples. Potential determinants of depression.
Results: Clinically signicant depression in adolescent girls with PCOS was not increased compared with the community sample (OR 1.3;
95%CI 0.7-2.7, P 5 .42). Within the PCOS cohort, depression was correlated with increased BMI (P 5 .01) and possibly acne (P 5 .08).
Conclusions: Lean adolescent girls with PCOS did not have more clinically signicant depression than girls in the community. Within the
PCOS cohort, however, there was a clear association between higher depression scores and elevated BMI. There is a potentially important
interaction between obesity and depression in PCOS.
Key Words: Polycystic ovary syndrome, Depression, Body mass index, Reynolds Adolescent Depression Scale

Introduction sparse and conicting.2,3 There is little data on quality of life

Polycystic ovary syndrome (PCOS) is the most common
endocrine disorder to affect females of reproductive age.
PCOS is characterized by oligomenorrhea and androgen
excess symptoms, which may in turn reduce quality of life
and depress mood. PCOS is a condition that can present
throughout most phases of the lifespan. To date research
has focused on adult women with PCOS. It is possible
that adolescent girls with PCOS present a different clinical
picture.
There are reports that PCOS in adult women is associated
with increased depression, anxiety, eating disorders,
obsessive-compulsive symptoms, and reduced quality of
life,1e7 but these have not been consistent ndings.8,9
Factors which may be associated with depression and
poorer quality of life in PCOS women include higher body
mass index, (BMI), androgen excess symptoms, and sub-
fertility, but data examining these possible relationships are
No external funding was required and the authors have no conicts of interest to
disclose. Informed consent was obtained after the involvement in the study was
fully explained and approval was given to the study by the Northern Regional Ethics
Committee. The methods of the study were in accordance with the ethical stan-
dards of this committee.
* Address correspondence to: Stella R. Milsom, FRACP, Fertility Associates, Ascot
Central, Private Bag 28910, Remuera, Auckland 1541; Phone: 09 520 9520; fax: 09
520 9521
E-mail address: s.milsom@auckland.ac.nz (S.R. Milsom).
1083-3188/$ - see front matter 2013 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jpag.2012.11.013
and prevalence of depression in adolescents with PCOS10,11
which is of concern given that adolescent girls are at
signicant risk of depressive illness even in the absence of
organic disease.12,13
The aim of our study was to assess the prevalence of
clinically signicant depression in adolescent girls with
PCOS presenting for clinical care, to determine whether
depression in adolescents with PCOS is associated with BMI,
androgen levels, or clinical symptoms of PCOS, taking age,
ethnicity, and socioeconomic grouping into account in the
analyses, and to compare the prevalence with prevalence
rates found in a large nationally representative school based
survey.
Materials and Methods
Subjects
The survey was offered consecutively to adolescent girls
with PCOS who presented to a specialist reproductive
endocrine service in Auckland, New Zealand, serving
patients from the upper North Island catchment area of
approximately 2 million people between 2007 and 2009.
Subjects were diagnosed as having primary PCOS using
the Rotterdam criteria, after excluding secondary causes
of PCOS such as classical and non-classical adrenal
 S.R. Milsom et al. / J Pediatr Adolesc Gynecol 26 (2013) 142e147
hyperplasia, testosterone secreting lesions, and prolactin or
cortisol excess. The diagnosis of PCOS was made by 1 of 2
specialist reproductive endocrinologists (S.M. and M.O.).
Young women who did not possess reading and compre-
hension English skills of at least Year 6 level were excluded
because the data collection involved completing survey
questions in English.
The comparison group of adolescents was derived from
the Auckland portion of the Youth 2007 study. Youth 2007
was a New Zealand-wide computer-assisted survey of a
representative sample of nearly 10,000 secondary school
students (school years 9-13) in which data were collected on
health and well-being, and specically mood and quality of
life. Exclusion criteria for participation in Youth 2007
included lack of reading and comprehension English skills to
at least Year 6 level, because the data collection involved
completing survey questions in English. The subset included
as a comparison group for this study were all females
surveyed from Auckland schools, aged 14-19 years, and of the
same ethnic groups present in the school students in the
PCOS study cohort. The variables available from Youth 2007
for comparison with the PCOS group were age, ethnicity,
deprivation index, BMI, and RADS short form. As the demo-
graphics of the PCOS sample were expected to differ from
that of the general school population all comparisons made
included age, ethnicity, and deprivation index to allow
adjustment for imbalances in these characteristics.
Ethics approval was obtained from the Northern Regional
Ethics Committee (Approval Number NTX/06/07/083).
Measures in PCOS Group
Participants completed 2 questionnaires comprising
the RADS-2 questions14 and a demographic and symptom
questionnaire designed specically for this study. The
condential questionnaires were administered to study
participants in a private room separate from the clinic with
no time constraints and without any family or medical staff
present. Participants were aware that results would not be
communicated to parents or family unless specically
requested. Participants whose scores fell into the clinical
range for depression were contacted to inform them of this
result and to suggest they seek further support from their
general practitioner.
Clinical information was extracted from patient records.
Consent was obtained from all participants, including a
guardian or parent if the participant was less than 16 years
of age.
Depression Rating Questionnaire
The Reynolds Adolescent Depression Scale (RADS-2),14
a self-scoring depression rating scale designed for adoles-
cents, was used to screen for clinical depression. RADS-2 is
based on DSM-III criteria to ensure construct validity. The
RADS-2 score has demonstrated internal reliability, high
sensitivity, and specicity (89% and 90% respectively), and
excellent correlation with other measures of depression.15
As a shortened form of RADS-2 (RADS-2SF) has shown
good correlation with the long form of RADS-2 (RADS-
143
2LF),16 the RADS-2 questionnaire may be administered in
either short or long form. RADS-2 is the recommended
questionnaire for community screening for depression in
adolescents and is the only depression score validated for
use in adolescents in New Zealand.16,17
The long form of the RADS-2 (RADS-2LF) comprises 28
questions. In the long form, the cut-off for clinical depres-
sion is dened as either: a total score of O76, or 4 out of 6
critical items endorsed as positive as prescribed by the
RADS manual.15 The short form of RADS-2 comprises 10 of
the original 28 questions found in the long form of RADS-2.
In the New Zealand population, the cut-off for clinical
depression on the Short Form is dened as either: a total
score greater or equal to 28, or a positive answer on 4
critical items.16
The PCOS cohort was administered the long form of
RADS-2. To enable us to compare these data with those of
the young people in the Youth 2007 comparison group who
were administered the short form RADS-2 only, the relevant
10 questions from the long form surveys were extracted for
our cohort.
Symptom and Demographic Questionnaire
A study-specic questionnaire was designed by S.M. and
M.O. to collect socio-demographic information on partici-
pants in the study group. The questionnaire included
questions regarding ethnicity, address, co-inhabitants in the
household, and the school attended. Socio-economic status
of participants was assessed using the patient's home
address to code the deprivation score of the area of resi-
dence. The deprivation score combines 9 variables about
households within meshblocks to form a score, using the
2006 NZ census.18 Meshblocks are the smallest geographic
unit for which statistical data is collected by Statistics New
Zealand, usually about 50 houses, with each meshblock
abutting another and covering the whole of New Zealand.
The deprivation scores are divided into deciles with decile
10 representing the most deprived 10% of small areas. This
method was also used to determine socioeconomic status in
the Youth 07 survey.
We collected information on the perceived severity of
PCOS-related symptoms in the participants in order to
assess whether the subjective severity of symptoms was
associated with depression. The survey asked participants
to grade the severity of the following symptoms acne,
excess facial or body hair, overweight, and irregular
periods as: not a problem, mild, moderate, or
severe. The descriptions of severity selected by partici-
pants were then converted to severity scores of 0 to 3.
We quantied the clinical severity of the physical fea-
tures of PCOS objectively in order to assess whether
objective or subjective severity of symptoms was related to
the likelihood of clinical depression. The objective assess-
ments of severity were made by the endocrinologist at the
time of diagnosis. Acne severity was rated as mild,
moderate, or severe; hirsutism was graded using the
Ferriman-Gallwey score (!8 5 normal, 8#15 5 mild,
15-22 5 moderate, O22 5 severe), and BMI was calculated
from the height and weight. Menses were graded as
144 S.R. Milsom et al. / J Pediatr Adolesc Gynecol 26 (2013) 142e147

follows: menstruation at least every 35 days 5 normal; 6-8
weekly 5 mild disturbance; 2-6 monthly 5 moderate
disturbance; and menstrual periods more than 6 months
apart 5 severe. Prescription medications were recorded.
Laboratory Data
Laboratory and clinical data from the PCOS cohort were
collected from the subjects' clinical records. Testosterone
level (Total T) at diagnosis and before therapy was
measured in the Auckland Community laboratory by the
Abbott Architect testosterone assay and re-analyzed by the
Auckland District Health Board laboratory by a second
generation Roche testosterone assay if the initial level was
more than 50% above the normal range. The latter level was
recorded when there was a discrepancy. The inter- and
intra-assay coefcient of variation for these assays is
between 4% and 8%. Clinical data recorded included BMI,
Ferriman-Gallwey score, assessment of acne score graded 1-
5 in severity, and menstrual history.
of selection within different schools, the data were analyzed
including the cluster effect of school and the appropriate
weights. The PCOS participants were given a weight of 1 and
an individual cluster. The analyses for the 2 outcomes were
run in the SAS SURVEYLOGISTIC and SURVEYREG survey
procedures respectively.
BMI was not included in the original variables adjusted
for in the comparison of groups because it is possible that
BMI could be associated with PCOS and its inclusion could
therefore be overcorrecting the model and concealing the
effect of PCOS.
However, the analyses were also run with the inclusion
of BMI as an explanatory variable to investigate whether
this modied the association of group with depression. The
interaction of group and BMI was also investigated to see
whether there was any indication that the relationship of
BMI with depression differed in the PCOS group and the
general population.
Power

Statistical Analysis
The study was designed with 100 PCOS participants to
have 80% power to detect a doubling in the odds of being
The prevalence of clinically signicant levels of depres- depressed in the PCOS group compared to the control
sive symptoms in the PCOS cohort was determined by using group, at the 5% level of signicance.
the cut-offs on the RADS-2LF in the manual (outlined
Results
above). To investigate whether there were particular char-
acteristics of the adolescents with PCOS which made them
The survey was offered to 103 eligible consecutive
more at risk of depression, linear and binary logistic
adolescents with PCOS, all of whom agreed to participate.
regressions were applied to the data for the whole PCOS
102 adolescents went on to complete and return the
sample with the RADS-2LF score or reaching the RADS-2LF
surveys, of which 92 participants were recruited from
depression threshold, respectively, as the outcome. In this
private sector and 10 participants from public (government
analysis, the explanatory variables were age, ethnicity,
funded) sector tertiary reproductive endocrine clinics.
deprivation score of the meshblock where they lived, time
Table 1 describes the characteristics of the whole PCOS
from diagnosis, objective measures of menstrual cyclicity,
cohort (n 5 102). Their median BMI was 22.1 with 10th and
BMI, acne, total testosterone, whether they were at school,
90th percentiles of 18.5 and 32.0 respectively. The preva-
and whether they were taking oral contraceptives.
lence of clinical depression in the whole PCOS cohort was
In order to compare the level of clinical depression in
12% (12/102) by RADS-2LF criteria (mean score, SD 56.6,
PCOS adolescents presenting to an outpatient endocri-
15.8). The PCOS cohort included 7 girls who were taking
nology service with adolescent girls of the same age in the
antidepressant medication, 3 of whom reached the RADS-
Auckland school population, the RADS-2SF scores from the
2LF criteria for depression when surveyed.
females in the Youth 07 survey were compared with the
RADS-2SF scores which were extracted for the participants
Table 1
in the PCOS study who were at secondary school. As the Demographic Data and RADS-2 Scores of PCOS Girls
PCOS participants were aged 14-19 and none were of Pacic
Age (mean, SD) 17.0, 1.5
Island ethnicity, the Youth 2007 comparison data set Ethnicity (%)
was restricted to females aged 14-19 attending school in NZ European 81
Asian 5
Auckland who were not of Pacic ethnicity. All comparisons Maori 6
included age, ethnicity, and deprivation index to remove Other 8
any confounding effects of these variables. Two analyses NZDep score (%)
Decile 1-3 74
were run, one using the binary outcome of whether or not Decile 4-6 14
subjects were above the RADS-2SF screening cut-off for Decile 7-10 13
clinical depression, and the other using the RADS-2SF score Menses O5 weeks (%) 69
Total T above normal range (%)* 66
as a continuous measure. For both analyses, group (Youth $Mild acne (%) 66
2007 or PCOS) was the explanatory variable of interest, but BMI kg/m2 (median, range) 22.1 (17.5-40.0)
age, ethnicity, and deprivation score derived for the subjects Ferriman-Gallwey score O7 (%) 42
Antiandrogen treatment (%)y 46
from their meshblock of residence were also included to Antidepressant treatment (%) 7
adjust for differences in the distribution of these variables.
* Total testosterone O2.5 (normal female range 0.5-2.5 nmol/L).
As the Youth 2007 was a clustered sample (school was the y
Antiandrogen medication is any combination of oral contraceptive, metformin,
primary sampling unit) with slightly different probabilities spironolactone, and cyproterone.
 S.R. Milsom et al. / J Pediatr Adolesc Gynecol 26 (2013) 142e147
Within the PCOS group there was strong correlation
between the subjective and objective measure of BMI
(Spearman correlation .82) and moderately strong correla-
tions between the subjective and objective measures of
acne (.48), menstrual disturbance (.59), and hirsutism (.55).
Only the objective measures were therefore included in
analyses.
Within the whole PCOS group, there was a strong associ-
ation between BMI and RADS-2LF depression score (P 5 .01)
with overweight PCOS girls more likely to have a higher
RADS-2LF score (Table 2). There was also weak evidence of an
association of acne and RADS score (P 5 .08) with PCOS girls
with worse acne more likely to have a higher score. There
was no association of total testosterone level, menstrual
disturbance, oral contraceptive use, time since diagnosis,
school attendance, age, ethnicity, or socioeconomic grouping,
with the RADS score or the likelihood of being clinically
depressed.
To compare depression between our cohort of young
women with PCOS attending for clinical services with the
national community sample comprising secondary school
students, the PCOS cohort was restricted to those attending
school (n 5 66). We used the demographics of this sub-
group to provide the most appropriate comparison group
from the national school based survey data and extracted
data of the non-Pacic Island females attending school in
Auckland, aged 14-19 (n 5 1349) from the national survey.
Fifty percent of these were Europeans, 24% Asian, and 17%
Maori. Seventy-nine percent were 16 years or younger and
47% lived in areas with NZDep Score 1-3. Their median BMI
was 21.8, range 14.9-62.5.
The prevalence of clinical depression in PCOS girls
attending school (n 5 66) was compared with the girls in the
Youth 2007 group using the RADS-2SF criteria. The raw
percentages categorized as clinically depressed, not adjusted
for demographic differences were 15.7% in the Youth 2007
school sample compared to 15.2% in the PCOS group
attending school. Having adjusted for demographic differ-
ences, although the estimated odds of depression were
slightly higher in the PCOS sample, there was no evidence
that this small observed difference was likely to be real
(OR 1.3; 95%CI 0.7-2.7, P 5 .42). After adjustment for BMI, this
nding did not change (OR 1.4; 95%CI 0.8-2.6, P 5 .24).
Similarly, although the observed total RADS-2SF scores
were slightly higher in the PCOS cohort than in the Youth
Table 2
Results of Regression Analysis within the PCOS Group with RADS Long Form Score as
the Outcome
Parameter Estimate Standard Error
Age (y) 0.41 1.62
Ethnicity
Asian vs Maori 4.58 8.90
Euro/Other vs Maori 2.22 7.57
NZDep 2006 (1-10) 0.23 0.78
Menstrual (1-4) 1.73 1.50
Acne (0-3) 4.03 2.27
BMI (kg) 0.85 0.33
Time since diagnosis (mo) 0.05 0.15
Total T level 1.65 1.62
Attending school 4.77 5.14
OCP vs not .89 3.54
145
2007 girls, this difference was not signicant (b coefcient
estimate for PCOS compared to Youth 07 0.43, standard
error (SE) 0.71, P 5 .55). The estimate for the effect of group
changed only slightly with the inclusion of BMI (b coef-
cient 0.34, SE 0.69, P 5 .63).
Discussion
Ours is the rst substantive study to measure clinical
depression as a primary outcome in adolescents with PCOS
presenting for treatment. It is one of a very few studies in
which there is a substantial comparison group from the
community. In contrast to the majority of adult studies
in PCOS women, we did not nd a high prevalence of
depression in our adolescent cohort compared with rates in
the community. We examined factors potentially associated
with depression and found a strong relationship with BMI
and a possible relationship with acne, but no relationship
with androgen levels, oral contraceptive use, objective
symptom severity, age, ethnicity, and socioeconomic status.
Other published data on mental health in adolescents
with PCOS is extremely sparse. A small Greek study of 22
PCOS adolescents using the Beck Depression Inventory and
State-Trait Anxiety Inventory as assessment tools found
PCOS to be associated modestly with anxiety but not with
depression when compared with eumenorrheic controls.11
Our nding, in a larger cohort of PCOS girls, supports and
extends the conclusions of this study.
In contrast, most1e7 although not all8,9 studies in adult
PCOS women report higher rates of depression (14%-64%)
when compared with the general adult female population
(12%-14%). Methodology issues such as small sample size,
varying criteria for diagnosis of PCOS, inconsistent diagnosis
of depression by self report or non-validated questionnaires,
PCOS cohorts of varying BMI, and poorly matched or lack of
control subjects may account for some of this variation. Two
recent meta-analyses19,20 have attempted to determine the
prevalence of depression in adult PCOS women but reached
substantially different conclusions concerning the preva-
lence of PCOS adding to confusion in this area. Barry et al,19 in
a meta-analysis of 910 PCOS women, found PCOS women to
have only a mild increase in depressive symptoms, whereas
the meta-analysis from Dokras el al,20 of 522 PCOS women
which was published 6 months earlier concluded depression
scores in PCOS women were increased 4-fold.
Our nding of a strong correlation between BMI and
depression is of interest. This has not previously been
examined in adolescents, because the Laggari study11 was
not powered to evaluate the relationship between BMI and
P value depression scores, but BMI is closely correlated with a lower
.80
quality of life in adolescents with PCOS.10 Our PCOS cohort
.87 was relatively lean. In adult women with PCOS, the rela-
tionship of BMI and depression is conicting. In general,
.76
increased rates of depression are found in overweight and
.25 obese cohorts of PCOS women,1,3e5,7,21,22 whereas data from
.08 leaner PCOS cohorts is more mixed with some authors
.01
.74
reporting an increased prevalence of depression23e26 and
.31 other groups nding no difference.8,9 Relatively few studies
.36 have used BMI-matched controls.1,9,23,26 Although data
.80
from these studies are also mixed, most report an increase
146 S.R. Milsom et al. / J Pediatr Adolesc Gynecol 26 (2013) 142e147
in depression scores in PCOS women in comparison to
control data even when matched for BMI,1,23,26 albeit not
conrmed by Jedel et al.9 This suggests that in adult women,
factors other than BMI, as yet not dened, may be associ-
ated with the increased prevalence of depression found in
most studies of PCOS women. However, a more modest
contribution of BMI to increased risk of depression has not
been excluded and further data from larger studies of
women and adolescents where BMI has been adjusted for
are needed.
We found possible evidence that depression in our PCOS
cohort was associated with acne but not with initial androgen
levels. This relationship has not been examined elsewhere in
adolescents but in adult PCOS women, somewhat surpris-
ingly, no signicant association between androgenic symp-
toms and depression scores has been demonstrated.2,4,5,8,21 In
adult PCOS women, while an apparent curvilinear relation-
ship between androgens and depression was reported by
1 group,1 others did not conrm this relationship2,3,21,25,27e29
and the relationship between testosterone and depression
remains complex and poorly understood.
It has been suggested that subfertility may be a risk for
depression in PCOS women,30,31 although currently there
are no robust data with which to conrm or refute this
association. Our cohort was too young for concerns about
subfertility to be a major factor, but we did not specically
investigate this.
We found no difference in depression scores between girls
on antiandrogen treatment and those who were not (data
not shown). Again, the effect of antiandrogen therapy on
mood has not been examined elsewhere in adolescents with
PCOS but cross sectional data from adult PCOS cohorts is
consistent with little or no effect of antiandrogen therapy on
self-reported mood scores.19 Additionally, a prospective
study in a Turkish cohort of PCOS women32 has reported that
depression scores are not impacted on by 6 months of oral
contraceptive treatment. However, the effect of antiandrogen
therapy on depressive symptoms in PCOS women remains
somewhat uncertain and warrants further investigation.
There are a number of limitations to our study. We
recruited young women in the same age range as those in
the Youth 07 study, but in the event, and to our surprise,
only two-thirds of our cohort attended school. In retrospect
we should have taken this into account in our study design.
To deal with this, for our primary analysis, we restricted our
comparisons to those attending school. This reduced the
power to show a difference in depression between groups.
However the scores and prevalence of depression between
the 2 groups are so similar that a very large sample would
be needed to show a statistical difference, if there is one,
and this is unlikely to be clinically signicant. Recruitment
of PCOS subjects was via outpatient appointment which
may lead to bias in that girls with more severe depression
may not be motivated enough to attend. However, because
almost all adolescents attended with family members, we
considered this was unlikely to be an important confounder.
We were not able to exclude PCOS in the Youth 07 group
because this was not one of the measures in the survey, and
this might have reduced the differences between groups.
However, assuming 8%-11% of the Youth 2007 community
comparison group have PCOS33 and 15.2% are depressed
(the % of the PCOS school sample depressed) then the
estimated odds ratio for depressed in the PCOS sample
compared with the youth 2007 sample would increase only
slightly from 1.3 to 1.37 suggesting this is not a major
confounder. In 2010 controversy over methods of diagnosis
of PCOS in adolescent girls occurred.34 We have used the
standard of diagnosis at the time of recruitmentdthe Rot-
terdam consensus criteria. We believe that these criteria
remain appropriate until consensus is reached on further
diagnostic criteria specic for adolescent girls.
Despite these limitations there are signicant strengths to
this study. We gathered the data prospectively in a relatively
large consecutive group of girls attending clinical services.
The only other comparable study in adolescents included
only 22 participants. We accessed a large community sample
to provide a comparison group allowing adjustment for
age,13 ethnicity, socioeconomic grouping, and school atten-
dance and in which depression scores were primary
outcomes. This is in contrast with many of the studies in
adult PCOS women and the previous adolescent study which
relied on a small convenience sample for comparison. We
were able to recruit almost 100% of eligible PCOS patients.
Our study participants were diagnosed with PCOS by 1 of 2
endocrinologists using a well described clinical denition of
PCOS (the Rotterdam consensus). We have measured
depression using a depression scoring system specically
developed for adolescents demonstrating excellent internal
consistency and validated both internationally35,36 and
within New Zealand.16,17 This is likely to be a more appro-
priate measure of depression than studies that assess
depression using questionnaires validated only in adult or
hospital populations.
Depression is common in young women12,37 and mostly
untreated38,39 and we would advise all clinicians to screen
for depression in young women presenting with health
issues. Our data does not show an increased risk for
adolescent New Zealand girls with PCOS, however. Our
nding of a strong association with BMI is important. In
future studies, the association between BMI, subfertility,
and antiandrogen treatment and depression should be
addressed. More research with a developmental perspec-
tive is required to determine why there is a difference in
ndings between our study in adolescents and the studies
in adult cohorts. In the meantime adolescent girls with
PCOS should be encouraged to maintain a healthy lifestyle
to prevent increases in BMI.
Acknowledgments
We would like to thank the girls who participated in the
study, Dr Simon Denny for allowing access to the Youth 07
data set, and the Adolescent Health Research group in
general.
S.M. conceived and designed the trial. S.N. wrote the
ethics application and extracted the clinical data. S.M. and
M.O. recruited the patients and supervised the surveys.
S.M., M.O., S.N., S.N.M., and J.S. provided trial oversight.
J.S. analyzed the data. S.M., S.N., S.N.M., and J.S. wrote the
paper.
 S.R. Milsom et al. / J Pediatr Adolesc Gynecol 26 (2013) 142e147 147

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