CONTEXT: Patients with polycystic ovary syndrome (PCOS) are at high risk of depression, anxiety, and metabolic syndrome (MetSyn), a key predictor of cardiovascular disease. The impact of depression and/or anxiety on MetSyn is unknown in this population. OBJECTIVE: To compare the risk of developing MetSyn in patients with PCOS with and without a history of depression and/or anxiety. METHODS: Retrospective longitudinal cohort study (2008-2022) with median follow-up of 7 years at a tertiary care ambulatory practice. Patients with hyperandrogenic PCOS and at least 2 evaluations for MetSyn ≥3 years apart (n = 321) were included. The primary outcome was risk of developing MetSyn. We hypothesized that this risk would be higher with a history of depression and/or anxiety. RESULTS: At the first visit, 33.0% had a history of depression and/or anxiety, with a third prescribed antidepressants or anxiolytics. Depression and/or anxiety increased risk of developing MetSyn during the study period (adjusted hazard ratio [aHR] 1.45, 95% CI 1.02-2.06, P = .04) with an incidence of MetSyn of 75.3 compared with 47.6 cases per 100 person-years among those without (P = .002). This was primarily driven by depression (aHR 1.56, 95% CI 1.10-2.20, P = .01). CONCLUSION: Patients with PCOS and depression and/or anxiety have a high risk of developing MetSyn, with a stronger association between depression and MetSyn. Our findings highlight the urgent need for guideline-directed screening for depression and anxiety at time of diagnosis of PCOS as well as screening at subsequent visits to facilitate risk stratification for metabolic monitoring and early intervention in this high-risk group.