|Year : 2018 | Volume
| Issue : 4 | Page : 208-213
A cross sectional survey on quality of life and psychiatric morbidity in women with polycystic ovary syndrome
Divya Korampatta1, Prakash Mangalasseri2, Anitha K Viswambharan3
1 Department of Kayachikitsa, JSS Ayurveda Medical College, Mysore, Karnataka, India
2 Department of Kayachikitsa, VPSV Ayurveda College, Kottakkal, Kerala, India
3 Department of Prasuti Tantra Evam Stri Roga, VPSV Ayurveda College, Kottakkal, Kerala, India
|Date of Submission||13-Jan-2018|
|Date of Decision||28-Dec-2019|
|Date of Acceptance||08-Jun-2021|
|Date of Web Publication||04-Jan-2022|
Dr. Divya Korampatta
Othaloor Mana, Vellarakkad Post, Thrissur Dt, Kerala
Source of Support: None, Conflict of Interest: None
Background: Polycystic ovary syndrome (PCOS) is a multisystem disorder having a great impact on psychological and social functioning resulting in reduced Quality of life (QOL). Methodology: Women diagnosed with PCOS as per the Rotterdam criteria, in the age group of 18-40 without any history of psychiatric illness and recent stressful life events or trauma attending the OPD of Prasuti tantra evam Striroga of a tertiary care Ayurveda hospital were recruited for the study. A cross sectional study in 50 eligible women was carried out with World Health Organization Quality of Life questionnaire (WHOQOL-BREF), Symptom Checklist 90 R (SCL-90 R) to assess QOL and psychiatric morbidity respectively. As an important measure of QOL, sexual satisfaction was also measured with Visual Analogue Scale (VAS). Results: QOL was less than the mean value in 74% in the psychological domain and 68% in social domain and 62% each in physical and environmental domain indicating poorer QOL. On detailed psychological screening, mean scores of depression, obsessive- compulsive and anxiety domains were higher. Sexual satisfaction was moderate to high in married participants. Conclusion: Psychiatric morbidities are highly prevalent in PCOS women and they have reduced QOL. These psychiatric morbidities should be addressed for better outcome in PCOS management.
Keywords: Anxiety, Ayurveda, depression, psychological wellbeing
|How to cite this article:|
Korampatta D, Mangalasseri P, Viswambharan AK. A cross sectional survey on quality of life and psychiatric morbidity in women with polycystic ovary syndrome. Ancient Sci Life 2018;37:208-13
|How to cite this URL:|
Korampatta D, Mangalasseri P, Viswambharan AK. A cross sectional survey on quality of life and psychiatric morbidity in women with polycystic ovary syndrome. Ancient Sci Life [serial online] 2018 [cited 2022 Jan 21];37:208-13. Available from: https://www.ancientscienceoflife.org/text.asp?2018/37/4/208/334721
| Introduction|| |
'Dignity in mental health' is the focal theme of discussions in the current mental health scenario. Despite being common, mental illness is often undiagnosed by doctors in many of the primary health care settings. Striking gender differences are found in the patterns of mental disorders, especially depression, anxiety and somatic complaints, which are higher in females. Gender based roles, stressors and negative life experiences and events are the coexisting risk factors which have significant relation to the higher rates of depression, anxiety and somatic complaints. In addition to the vulnerability, a diagnosis PCOS further warrants psychological evaluation in females to rule out clinical or subclinical stage of psychiatric morbidities especially neurotic spectrum disorders and mood disorders.
The prevalence of PCOS has increased with the use of different diagnostic criteria and in the first community-based prevalence study with current Rotterdam diagnostic criteria, has recently been shown to be 18% (17.8 ± 2.8%). In recent years, there is a sharp rise in the incidence of PCOS among reproductive aged women in India. Obesity is common in women with PCOS and is linked to failure or delayed response to the various treatments proposed to other symptoms. Another social and economical burden of PCOS in Kerala is the high infertility rates as high as 33% of total infertile women. Psychological distress aggravates all major symptoms of PCOS and cause further deterioration in the QOL of PCOS women.
A study from Sri Lanka demonstrates significant psychological distress in 32.9% of community-based women with PCOS when compared with normal controls from the same community setting who had no psychological affliction. Another clinic-based study from India, reports that 54% of women with PCOS has significant distress. The prevalence of depression in women with PCOS is higher (28–64%), than for women in the general population (7.1 –8%). The prevalence of anxiety in women with PCOS ranges from 34 to 57% yet again a higher prevalence than for women in the general population (18%).
Many of the recent researches showed that certain personality traits and attitudes are frequently observed in PCOS women. So, not only by the symptoms, but also by an emotional vulnerability, PCOS women need attention from a mental health professional. As the data available on psychological aspects of PCOS in our settings was very little, a descriptive cross sectional survey to measure the Quality of life and psychiatric morbidity was planned. An additional measure of sexual satisfaction in married women was also carried out.
| Methodology|| |
Patients were recruited from the outpatient department of Prasuti tantra evam stri roga, VPSV Ayurveda College Kottakkal during a period of 18 months from 2014 to 2016. Women with symptoms of PCOS visiting other OPD's were referred to Prasuti tantra evam stri roga OPD for expert evaluation and diagnosis conformation. Two days in a week were randomly selected and all patients visiting the OPD on those days were screened by an expert in Prasuti tantra evam stri roga and confirmed the diagnosis of PCOS according to the Rotterdam criteria 2003, with a possible exclusion of other pituitary, adrenal and ovarian diseases. Sample size was calculated based on the available prevalence rate of 15% of PCOS in 17-35 age groups in Kerala. The estimated number was 49 and it was rounded to 50. Women in the age group of 18-40 who were willing to give written consent were included irrespective of their marital status. Women under psychiatric/other medication, recent stressful life events/trauma and other major systemic diseases were excluded.
Variables and measures
Details of age, domicile, occupation, economic status, religion were recorded in a prepared case record form. Other variables were general QOL, psychiatric morbidity and sexual satisfaction which were measured by WHOOL-BREF, Symptom Checklist -90 Revised (SCL-90 R) and Visual Analogue Scale (VAS) respectively. The WHOQOL-BREF is an abbreviated 26-item version of WHOQOL-100, has four domains related to quality of life, i.e. physical health, psychological health, social relationships and environment, giving four scores relating to the four domains. Answers to all questions were rated on a Likert scale of 1–5 and the score for each domain was transformed into a 0–100 score, where high values represent a better quality of life. SCL-90 is a psychiatric self-report inventory. The 90 items in the questionnaire are scored on a five-point Likert scale, indicating the rate of occurrence of the symptom during the time reference. SCL 90 assesses psychological distress in nine areas (Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Aggression, Phobia, Paranoid Ideation and Psychoticism), as well as on three global categories (Global Severity Index – fundamental indicator of overall distress, the Positive Symptom Distress Index – intensity of distress, Positive Symptom Total – number of distress-inducing symptoms).Higher scores on the scales of the SCL-90-R mean higher distress; individual scales cannot be interpreted in diagnostic categories.
All questionnaires were scored and analyzed according to the published guidelines. For VAS scales, the distance from 0 mm to the patient's mark was measured. Minimal explanation was given to the participants. Hence, observational error and expression bias were expected. All data were entered into Microsoft excel to calculate descriptive statistics. Normality of data was tested by Q-Q plot in SPSS graph pad version 16.0. Normality of data was analyzed with INSTAT soft ware by Kolmogorov – Smironov test (K-S test). The mean domains scores of WHOQOLBREF and SCL 90-R were compared to the available population mean with one sample t test with Welch's correction.
Ethical clearance was obtained with the number IEC/Doc/05/14 dated 28. 04.2016 from the Institutional ethical committee of VPSV Ayurveda College, Kottakkal. Any participant found of having serious psychological issues would be referred to Manassanthi OPD of VPSV Ayurveda College, Kottakkal for expert opinion and medication.
| Results|| |
Age of the participants was found to be normally distributed and the mean age observed was 26.68 ± 5.43. All participants completed secondary education, and 60% of them had graduation/Post graduation. Majority of the PCOS women were unemployed (64%) and from rural area (60%). Majority of them were from Hindu community (54%) and from middle class socioeconomic back ground (62%). 62% of the participants were married and 8% were divorcees; remaining 30% were unmarried.
Quality of life
For the first question on general quality of life rating the mean score was 3.55, which range between the status neither good nor poor and good. For the second question on how satisfied with the health, mean score was 3.25. Combining both the scores, overall quality of life score was 3.39. Higher scores in WHOQOL BREF indicate better QOL. Better QOL was observed in environmental domain, followed by social and relationship domain. Least QOL was observed in physical domain followed by psychological domain. But the social and relationship score was positively skewed because of ceiling effect by highest possible scores. The values are given in the [Table 1].
|Table 1: Domain scores in World Health Organization quality of life questionnaire BREF|
Click here to view
- Percentage of participants above and below median cut off range: As there was no cutoff value for QOL to determine good/poor QOL, median was taken as a cut off value. Scores which are less than or equal to median were taken as having poorer QOL; shown in the [Figure 1] below
- Highest number of participants had poor QOL in psychological domain (74%) followed by social and relationship domain (68%). This indicates morbidity in psychosocial wellbeing of PCOS women.
- Psychiatric morbidity: The mean values of depression, obsessive compulsive and anxiety domains were higher. Higher scores in the upper limit of range were observed in somatization, obsessive compulsive and interpersonal sensitivity domains. The mean and highest score percentages were equally elevated in the domains of depression (28.45 and 57.69 respectively) and obsessive compulsive (27.88 and 50 respectively) domains. Same trend can be seen in interpersonal sensitivity (47.22, 19.68), anxiety (42.5, 20.8), hostility (54.17, 19.65) and paranoid ideations (58.33, 19.10)
- Mean domain scores Vs other sample mean: The mean domain scores of the present sample was compared with that of German PCOS women measured by the same tool. The values are given in the [Table 2].
Sexual satisfaction was assessed in 31 participants having an active sexual partner. Nobody scored less than 3. One participant scored 4, two scored 5 and all others above 6. The mean score was 7.21 and standard deviation was 1.36. 54.84% participants were in the moderately satisfied group (3.1-7). 45.16% were in the good satisfaction range. Highest score was 9.5.
| Discussion|| |
Cross sectional survey was carried out in 50 eligible PCOS women yielded supportive data of reduced QOL and high emotional distress leading to psychiatric morbidity as expected in the light of previous studies.
Kumarapeli et al., reported the mean age of PCOS women as 25.6 ± 7.1 in south-east Asia. In India, Hussain et al., observed mean age as 24.77 and 39% of participants from the age group 21-25 and 40% in the age group 26-30. In the present study also, almost similar percentage of participants were in the age groups- 30% in 18-23 group and 43% in 24-29 group. This may be due to concern on real/expected infertility as a result of irregular menstrual cycle in these age groups.
Quality of life
Patients with PCOS are an at-risk group for psychological and behavioral disorders and reduced QOL (PCOS Consensus, 2012). Studies from different parts of world report lower health related QOL in women with PCOS than in controls.
Lowest QOL mean score in the present study was observed in physical health domain followed by psychological health domain. This might be because of the burden of symptoms on body and mind. The scores in social and relationship domain and environmental domain were seemingly high. But the number of participants scored less than or equal to median was highest in psychological domain (78%) followed by social domain (68%) indicating higher distress in these two domains. In other domains too, 62% participants scored below or equal to median.
A growing body of research suggests that reduced QOL is associated with depression in women both with and without PCOS. In a large population-based study, researchers found that depression in diabetes was an important co-morbidity to treat, particularly because of its severe impact on QOL. The additive effects of depression and poor QOL may impact adversely on physical symptoms, medication adherence and lifestyle management. The same may be true for women with PCOS, highlighting the need to address depression and QOL in PCOS management. It is difficult to know whether it is depression that influences perceived QOL or that poor perception of QOL increases depression. Generally, people use their current affective state to judge their overall current QOL, including wellbeing, social functioning and living conditions and treating depression is likely to improve the overall current QOL. It is likely that for women with PCOS, concurrent treatment of depression and PCOS symptoms could therefore mean an improved QOL.
Comparison with other sample mean
There was a statistically significant difference in physical and psychological domains of QOL, which was lower than respective Sri Lankan population mean assessed by a population based study conducted by Kumarapeli et al., As the participants of the present study were selected from the OPD, the physical and psychological impacts of PCOS may be higher. The environmental domain score was higher and statistically significant. This may be due to higher living standards in Kerala and majority of the participants from middle class or rich. No significant difference was observed in the domain of social and relationship domain.
Recent researches including multiple meta-analyses showed significant association of depression and anxiety with PCOS. In the present study, a mental health status screening was done for understanding the morbid tendencies with SCL 90 R and highest mean score was obtained in depression, followed by obsessive compulsive and anxiety domain indicating higher morbidity in these domains. Similar observations were reported by Hussain et al., in a study on prevalence of psychiatric disorders in PCOS in Kashmir. High rates of psychopathology, with 52.7% of the sample suffering from a psychiatric condition with higher rates of depression and anxiety disorders especially GAD, panic disorder and OCD were reported in that study.
Rassi et al., in 2010 found major depression in 26.4% of PCOS patients. But in the present study, depression was not evaluated with a rating scale, hence whether the depressive features were of mild/moderate/severe were not confirmatory. Mansson et al., in 2008 and Kerchner et al., in 2009 found 45% and 40% prevalence of depression in PCOS patients, respectively. Even though the domain scores didn't have a cut off score in SCL-90 R to predict depression, when mean cut off was calculated, 46% of participants scored more than the mean score in the depression domain. The mean was 28.45% and highest score was 58% of total scores. Hence the prevalence of depression was almost similar with the earlier mentioned studies. To measure the exact prevalence, specific tools to screen depression should be used.
In PCOS, owing to the changes in physical features due to hyperandrogenism such as hirsuitism, obesity, alopecia or acne, negatively influence their feminine identity. These are also culturally defined as unfeminine and undesirable, affects the social image of the patient. These physical characters often lead to social withdrawal and social isolation along with a negative self image and lower self esteem all of which are important risk factors for depression and anxiety disorders. The increased prevalence of depression can be explained by direct influence of high androgen levels on mood disturbances.
The domains of somatization, obsessive compulsive, anxiety and phobia (phobic anxiety) come under the anxiety spectrum disorders. In the obsessive compulsive domain, both the ratios of mean and maximum score to the total score were high (27.88% and 50% respectively). Same trend can be seen in Somatization (18%and 47.8%) and anxiety (42.5% and 20.8%). The maximum score was higher in phobic anxiety domain (50%). So the wellbeing of the population in the anxiety spectrum is at risk. Hussain et al., observed high prevalence of anxiety spectrum disorders; especially GAD, panic disorder, and OCD. The prevalence of anxiety in women with PCOS ranges from 34% to 57% yet again a higher prevalence than for women in the general population (18%).
A high level of anxiety can be explained by the fact that there are persistent fears of loss of sexuality, loss of fertility and anxiety of not being able to have children in the future. Most of the PCOS symptoms and their results may also contribute to anxiety.
The domains of interpersonal sensitivity, hostility, psychoticism, and paranoid ideation may come under the broad umbrella of psychotic symptoms. The mean and highest score proportions to maximum possible scores in interpersonal sensitivity (19.68 and 47.22), hostility (19.65 and 54.17) and paranoid ideations (19.10 and 58.33) were comparatively high whereas not high in psychoticism domain per se. But, the self-reported psychotic symptoms may be associated with perceived stress, depressive symptoms, and impulsivity, a path model was postulated in which psychoticism would lead to perceived hassles, depression, hostility, and hopelessness. In addition, given the recognized association between depression and hopelessness, it was predicted that depression would partially mediate the association between psychoticism and hopelessness.
A few studies demonstrate associations between self-reported psychotic symptoms, such as paranoid ideation in general population and stressful life events or perceived stress. Some investigations involving non-psychiatric participants also have found that expressions of psychotic symptoms, such as delusional ideation, hallucinations, or paranoia, correlate with depression, which often leads to feelings of hopelessness. One study suggested that self reported positive psychotic symptoms are associated with impulsivity in a sample of low income, non-psychiatric African Americans.
According to the continuum hypothesis, psychotic symptoms should be present not only in individuals identified as having psychotic disorders, but also in a proportion of individuals in the general population who do not meet clinical criteria for diagnosable psychosis. In fact, it has been suggested that paranoid ideation -a complex phenomenon likely to arise from social, cognitive, and biological factors -is almost as common as symptoms of anxiety and depression in the general population.
The interrelationship of anxiety, depression and physical illness is important to consider in women with PCOS. As negative mood can impact on physical (e.g., eating and sleeping patterns), psychological (e.g., motivation and feelings of worthlessness) and social factors (e.g., relationships with others), effective symptom management of PCOS is likely to be improved if existing anxiety and depression are effectively treated. Therefore, it is vital that women with PCOS are screened and assessed for anxiety and depression and offered appropriate interventions if required.
Comparison of mean domain scores with other sample mean
Elsenbruch et al. noticed that patients with PCOS had significantly greater scores in the dimensions of obsessive-compulsive, interpersonal sensitivity, depression and psychoticism. In the present study too, those domains had comparatively higher mean score. On comparing the mean of domain scores, statistically significant higher scores were obtained in obsessive compulsive, depression, anxiety paranoid ideation and psychoticism domains.
In general, women with PCOS had lower scores on appearance evaluation than controls, and women with lower scores on appearance evaluation were more likely to be depressed. Women with PCOS were less likely to feel that others would consider them good looking, they were more likely to dislike their physique, did not feel as sexually appealing and felt more physically unattractive than controls. The physical symptoms of PCOS, such as hirsutism and acne, may have made these women more focused on their appearance, implying a need to do something about their appearance, which ultimately may lead to increased depression. Placing greater emphasis on satisfaction with their health may make women with PCOS more anxious. Women who were less invested in their physical fitness were more likely to be depressed, and women with PCOS had lower satisfaction with their fitness than women without PCOS. This will lead to intrusive thoughts causing anxiety and finally depression. As infertility is a strong psycho-social stressor with multiple connotations in India, resultant psycho- morbidities will be more.
Importantly, the sample for this study was comprised of individuals with no prior psychiatric treatment history. Although their levels of psychotic-like symptoms would likely not meet a diagnostic threshold, these symptoms however could potentially result in clinically significant psychological morbidity. Thus, individuals reporting isolated psychotic symptoms or demonstrating significant levels of psychoticism are at risk in at least two ways. In the long-term, such individuals are likely to have an elevated risk for the development of psychiatric illnesses, such as mood or psychotic disorders. More immediately, however, those experiencing elevated levels of psychoticism are at risk for greater perceived stress in everyday life, more depressive symptoms, and increased hostility in interactions. Each of these, in turn, may be associated with a host of psychological and social disturbances.
| Conclusion|| |
Psychiatric morbidities are highly prevalent in PCOS women and they have reduced QOL especially in Psychological and social relationship domains. Morbid tendencies of anxiety, depression, obsessive compulsive and interpersonal sensitivity further warns the necessity of psychological screening. This morbidity will certainly reduce the treatment outcome and manifest as psychiatric illness during the course of time. Holistic approach of Ayurveda should necessarily be employed in diseases like PCOS by choosing appropriate medicines having action on the physical and psychological symptoms and by employing proper counseling (Satvavajaya cikitsa).
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]