Prevalence and associated risk factors for depression symptoms in adolescent girls with polycystic ovary syndrome: a hospital-based cross-sectional study

Background Depression symptoms are a growing concern for adolescent girls with PCOS around the world. However, relatively small samples have given varying reports of its prevalence and risk factors in previous studies. Therefore, there is an urgent need for further research on the prevalence and associated factors of depression among adolescent girls with PCOS. Methods A cross-sectional study was performed from October 2021 to May 2022 using a questionnaire and examination of the medical records of a convenience sample of 335 adolescent girls with PCOS. The Chinese version of the Children’s Depression Scale (CDI) was used to investigate depression symptoms. A multivariate logistic regression model was used to determine factors that were significantly associated with depression symptoms. Results The prevalence of depression symptoms was 36.12% among adolescent girls with PCOS. A multivariate logistic regression model identified significant factors as perceived social support (95% CI: 0.921 ~ 0.965%, p = 0.000), sleep quality (95% CI: 1.134 ~ 1.324%, p = 0.000), belief illness (95% CI, 1.040 ~ 1.102%, p = 0.000), hirsutism (95% CI, 1.292 ~ 4.392%, p = 0.005), and LH/FSH ≥ 2 (95% CI, 1.939 ~ 6.369%, p = 0.000). Conclusion Depression symptoms are an important problem among adolescent girls with PCOS in China. A comprehensive approach that encompasses social support, structured health education for the disease, and evaluation of the psychological status of PCOS girls with hirsutism (and) or LH/FSH ≥ 2 in time is important to minimize depression symptoms and improve psychological health among adolescent girls with PCOS.


Introduction
Polycystic ovary syndrome (PCOS) is a common endocrine metabolic disorder among women of reproductive age; the prevalence in adolescent girls is from 5.6 to 11.04% worldwide (1), and 10.26% of Chinese adolescent girls (2).Symptoms of PCOS include irregular menstruation, infertility, obesity, acne, hyperandrogenemia, and ovarian polycystic degeneration (3).PCOS also increases an individual's risk for cardiovascular disease, type 2 diabetes, and endometrial cancer (4).
Simultaneously, PCOS is significantly related to mental illness.A previous study reported that adolescent girls with PCOS are 2.4 times more likely to suffer from depression than normal girls of the same age (5,6).As a serious mental illness, depression presents with a depressed mood, decreased energy, loss of interest, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration (7).Depression has negative physical, psychological, social, and behavioral effects.In the adolescent population, more than 50% of suicides are related to depression (8,9), and it also interferes with the successful transition from adolescence to adulthood: approximately 25% of adults suffer from depression during adolescence (10).As for PCOS, life management is recommended by international evidencebased guidelines as the ideal treatment.Patients with PCOS can participate in better life management by improving their psychological status.Therefore, depression is a significant health issue that must be addressed in the management of adolescents with PCOS (11).
As early as 2013, the PCOS Endocrinology Society's clinical practice guidelines recommended identifying depression in adolescents with PCOS (5), and 2020 international evidence-based guidelines for adolescents with PCOS emphasize the need to manage depression (6).A number of previous studies showed the prevalence of depression symptoms in adolescent girls with PCOS.
However, in those studies, not only did the prevalence rate vary greatly, ranging from 12 to 60%, but the sample size was very limited; the largest number was 153 (12-15).As for the risk factors for depression among adolescents with PCOS, there were also very limited and inconsistent studies.According to Elsenbruch et al., (16) independent predictors of depression among adolescent girls were irregular or absent menstrual periods, infertility, the associated changes in appearance, and possible disturbances in sexual attitudes.Hopkins found that lower control was a predictor of greater depression among adolescent girls with PCOS (12).In the other two studies, there was no significant relationship between obesity, body mass index, acne, hirsutism, and insulin (INS) resistance and depression disorders in the PCOS group (17,18).
Assessing the prevalence and associated factors of depression among adolescent girls with PCOS is important for early identification and intervention to reduce the effect of depression on adolescent girls with PCOS.Therefore, there is an urgent need for further research on the prevalence and associated factors of depression among adolescent girls with PCOS based on a large sample.Here, we enrolled 335 adolescent girls with PCOS and conducted an observational study to evaluate the prevalence of depression and comprehensively analyze the risk factors.was used to determine the sample size by taking the prevalence of depression among adolescent girls with PCOS as 39.2%, as assessed by the CDI (14), with a 5% margin of error, 95% confidence, and a 10% non-response rate.The final sample size was 312.

Data collection procedures
The researchers identified potentially eligible adolescent girls with PCOS who visited the gynecology clinic.If the adolescent girls with PCOS fulfilled the inclusion criteria, they and their parent(s) were briefed on the nature of the study and invited to participate after obtaining verbal consent from both the adolescent girls with PCOS and their parent(s).
Then two researchers begin to collect data on adolescent girls with PCOS according to the following three steps: the first step is a validated online self-administered questionnaire consisting of sociodemographic information, duration of PCOS, exercise habits, perceived social support, sleep quality, and belief illness was provided to adolescent girls with PCOS, and who needed to fill out the questionnaire independently.In the second step, researchers collected the height, weight, hirsutism, and acne of adolescent girls with PCOS in the gynecological clinic.In the third step, researchers collected laboratory indicators such as thyroid-stimulating hormone (TSH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), total testosterone (TES), and INS from their medical records.

Depression symptoms
Our main outcome of interest was the provisional diagnosis of depression symptoms, which was assessed using the Chinese version of the CDI (21).The Chinese version of the CDI questionnaire has 27 items and 5 subscales of low self-esteem, negative affect, lack of pleasure, poor performance, and interpersonal problems.For each item, the response options range from 0 to 3, with 0 indicating the absence of symptoms, 1 indicating mild symptoms, and 2 indicating definite symptoms.The total scale score ranges from 0 to 54, with higher scores reflective of higher levels of depressive symptomatology, and a score of 19 indicated the presence of depressive symptoms.The total Cronbach's alpha value was 0.85 in the reported study, and the test-retest reliability was 0.75.
Frontiers in Public Health 03 frontiersin.org

Perceived social support
Perceived social support was measured with the 12-item Perceived Social Support Scale (PSSS) (22).The scale yields three subscale scores for family, friends, and significant others.Respondents answered each question using a 7-point Likert scale ranging from 1 = "very strongly disagree" to 7 = "very strongly agree." Higher scores indicate that subjects perceive more social support and are categorized as low (12-36), moderate , or high (61-84).The total Cronbach's alpha value was 0.927 in the reported study.

Sleep quality
Sleep quality was measured using an 8-item of Athens Insomnia Scale (AIS) (23).For each item, the response options range from 0 to 3, with 0 indicating no problem at all and 3 indicating serious problems.The total scale score ranges from 0 to 24, with higher scores reflecting lower levels of sleep quality; a score of 6 indicates poor sleep quality.For internal consistency, Cronbach's alpha was approximately 0.90, and the mean item-total correlation coefficient was approximately 0.70.

Belief illness
Belief illness was measured using a 9-item Brief Illness Perception Questionnaire (BIPQ) (24).For each item, the response options range from 0 to 10, and the total scale score ranges from 0 to 80, with higher scores reflective of higher levels of negative perception of disease.The questionnaire had an internal consistency coefficient of 0.831, and the test-retest reliability was 0.931 in the reported study.

Hirsutism
The modified Ferriman-Gallwey scoring system was used for the diagnosis of hirsutism (25).These areas included the upper lip, lower back, lower abdomen, and thigh.Values between 0 (no excess hair growth) and 4 (extremely disturbing hair growth) in patients may be evaluated.The total scale score ranges from 0 to 16, and patients with FG scores of 3 or higher are regarded as hirsute.

Acne
Acne was graded using the Rosenfield scoring system (26), which may be classified as mild, moderate, or severe based on the number, extent, and nature of the skin lesions and consists of six items with values between 0 (= no acne) and 5 (= cystic acne).The total scale score ranges from 0 to 5, with higher scores indicating more severe disease.

Statistical analysis
Data entry and analysis were performed using EpiData 3.1 and SPSS -version 21.Descriptive statistics were presented as percentages (n, %) and mean ± SD for continuous variables.We analyzed the differences in characteristics of PCOS girls with or without depression symptoms using bivariate logistic analysis, in which independent t-tests or chi-square tests were conducted.All independent variables with a p-value of <0.05 in the bivariate logistic analysis were candidates to enter the multivariable logistic regression model to control the confounding effect.A multivariable logistic regression model was used to identify factors associated with depression symptoms among PCOS girls, with a p-value of <0.05 with 95% CI was considered statistically significant.

Results
A total of 335 adolescent girls with PCOS were recruited for this study through convenience sampling, and all of the data were collected.This left an effective response rate of 100%.

Participant characteristics
Of the 335 adolescent girls with PCOS who were enrolled in the assessment, we have reported that 121 adolescent girls with PCOS were screened positive for depression symptoms with CDI at a cutoff point of 19, thus resulting in a prevalence of 36.12%.
Of the 335 adolescent girls with PCOS, the mean age was 17.66 ± 1.657 years old (ranging from 12 to 19 years old).The majority (60.60%) of the adolescent girls with PCOS included in this study were from rural, 179 (53.43%) had an education level of senior high school, the mean duration of the disease diagnosis was 6.2 ± 5.7 years, 232 of the adolescent girls with PCOS (69.25%) had no regular exercise, the mean BMI was 23.257 ± 4.426, 109 (31.0%) and 80 (23.89%) had hirsutism and acne, respectively.Of all adolescent girls with PCOS, 51.94% had the LH/FSH ≥ 2. Analysis of participant characteristics is shown in Table 1.

Factors associated with depression symptoms in adolescent girls with PCOS
In the univariate analysis, six factors were found to be significantly associated with depression symptoms in adolescent girls with PCOS, including having hormonal contraception medicines (p = 0.001), perceived social support (p<0.001), belief illness (p = 0.001), sleep quality (p = 0.001), hirsutism (p = 0.002), and LH/FSH ≥ 2 (p<0.001)(Table 1).

Discussion
The prevalence of symptoms of depression was 36.12%among adolescent girls with PCOS in China.Our research finds that six factors (such as social support, sleep quality, belief illness, hirsutism, and LH/FSH ≥ 2) play a critical role in depression symptoms among adolescent girls with PCOS.
To our knowledge, this was the first study with respect to the depression symptoms of adolescent girls with PCOS in China.In the present study, the 36.12%prevalence rate of depression symptoms is in line with a study conducted in Turkey at 39.2% (14), and the reasons for the phenomenon may be related to using the same CDI and the participants were all from the gynecology clinic department of a general hospital.However, the current finding is lower than two small sample studies conducted in America (n = 47 and n = 23), which found the prevalence of depression among adolescent girls with PCOS to be 60 and 56.5%, respectively (12, 13).On the contrary, the present study's finding is higher than a study conducted in New Zealand, which found the prevalence of depression symptoms among adolescent girls with PCOS to be only 12% (15).The variations might be due to differences in environmental factors, sample size, a tool for assessing depression, and multiple sources of participants.
According to this study, adolescent girls with PCOS who have lower levels of social support have a higher risk of developing depression.The finding corroborates the result of a previous study which was conducted in America (12).This may be explained as follows: PCOS is a common chronic disease, but public awareness and attention to this disease are insufficient.As a result, adolescent girls with PCOS are more likely to have a sense of isolation, increasing the risk of depression.
In the present study, we found that sleep quality is associated with depression symptoms among adolescent girls with PCOS.A systematic review and meta-analysis of cohort studies reported that there is an association between sleep disruption and depressive symptoms in children and youths (27).Another systematic review of the literature regarding sleep duration and mood in adolescents indicated that less sleep was associated with a 55% increase in the likelihood of mood deficits (28).
Different mechanisms have been proposed to explain the association between sleep problems and depression, such as a disruption of circadian rhythm, activation of inflammatory pathways, and altered neuroplasticity and learning (29), a reduction in prefrontal activity, and a decrease in functional connectivity between the prefrontal cortex and limbic regions (30), and the loss of a person's ability to shift attention away from repeated negative thoughts (31).
Our study demonstrated that belief illness was associated with depression symptoms among adolescent girls with PCOS.Similar to our findings, perceived stress of the disease was an independent risk factor for depression in women with PCOS (32).Many adolescent girls with PCOS reported being uncertain about many aspects of PCOS, and a study indicated that PCOS patients with higher negative perceptions of the disease and its clinical manifestations were more pronounced (33).
Body image is a multidimensional matter that includes the perception of people regarding self-appearance and related thoughts and feelings about it.Hirsutism, acne, and obesity as important influence factors of body image are common symptoms among  Frontiers in Public Health 06 frontiersin.orgwomen with PCOS.Our study found there was a positive association between hirsutism and depression symptoms in adolescent girls with PCOS.Many studies also found that hirsutism was an independent risk factor for depression symptoms in women with PCOS (33)(34)(35)(36)(37).The possible reason could be, first hirsutism is characterized by excessive terminal hair growth in a male-pattern distribution in female patients, including the face, chest, back, upper arms, thighs, and abdomen.The unwanted facial and bodily hair often led to the feeling of "not being a female," which may be theorized to contribute to the psychological burden in this population of relatively young women.Second hirsutism is one of the most important manifestations of high androgen levels, which has a close relationship with depression (38,39).Contrary to previous findings, which showed that there was a clear association between higher depression scores and elevated BMI among adolescent girls with PCOS (15).In the present study, we found no significant relationship between BMI and depression.This might be a result of the different sample sizes; in the present study, the sample size is 335, which is three times more than in the previous study.
In the present study, we found that LH/FSH ≥ 2 is significantly correlated with depression symptoms in adolescent girls with PCOS.This is consistent with the study by Feng et al., who reported that LH/FSH ≥ 2 is an independent risk factor for depression in patients with PCOS.The mechanism for this phenomenon is with the increase of LH/FSH ratio the incidence of menstrual disorders increased (40).Studies reported that there was a positive association between menstrual disorders and depression symptoms (41,42).

Limitations
Some limitations must be considered in the interpretation of these findings.First, although in our study we enrolled 335 adolescent girls with PCOS, which was relatively a larger sample size compared to the previous studies, it is not possible to generalize the results of the study considering that the sample was recruited in a single hospital.Second, it was not randomized but a convenience sample.The other limitations might be that the design of the study was cross-sectional, and temporality and causality between factors could not be assured.

Conclusion
In summary, approximately 36.12% prevalence of depression symptoms was observed among adolescent girls with PCOS in China.Moreover, our research finds that many factors (such as social support, sleep quality, belief illness, hirsutism, and LH/FSH ≥ 2) play a critical role in depression symptoms among adolescent girls with PCOS.Our results suggest the importance of a comprehensive approach at both individual and institutional levels to reduce depression symptoms among adolescent girls with PCOS.More specifically, a holistic strategy that encompasses social support (such as emotional and informational support from parents, peers, and medical staff), structure health education for the disease, and evaluation of the psychological status of PCOS girls with hirsutism (and) or LH/ FSH ≥ 2 in time.
A hospital-based cross-sectional study design was used.Adolescent girls with PCOS were recruited from the gynecology clinic department of the affiliated hospital of Zunyi Medical University.This study was carried out from October 2021 to May 2022.The inclusion criteria include: (I) aged 10-19 years old (19); (II) Rotterdam diagnostic criteria recommended by the PCOS China Diagnosis and

TABLE 1
Characteristics of PCOS girls with and without depression symptoms (n = 335).

TABLE 2
Factors associated with depression symptoms among adolescent girls with PCOS.