Osteoporosis and Depression
Abstract & Commentary
By Leon Speroff, MD, Professor of Obstetrics and Gynecology, Oregon Health and Science University, Portland. Dr. Speroff is a consultant for Warner-Chilcott.
Synopsis: Women with fractures have a greater prevalence of clinical depression.
Source: Silverman SL, et al. Prevalence of depressive symptoms in postmenopausal women with low bone mineral density and/or prevalent vertebral fracture: results from the Multiple Outcomes of Raloxifene Evaluation (MORE) Study. J Rheumatol. 2007;34:140-144.
Silverman and colleagues reported the prevalence of depression in a cross-sectional subset of 3798 women in 6 English-speaking countries, who participated in the Multiple Outcomes of Raloxifene Evaluation (MORE) trial.1 Depression was assessed by the Geriatric Depression Scale. Womenwith vertebral fractures recorded a greater number of depressive symptoms, accounting for a 6.6% prevalence and a 2.5% absolute increase compared with women without fractures. Women with 3 or more vertebral fractures had a 12.8% prevalence of depression.
Commentary
Because there are so many women with osteoporosis, a greater prevalence of depression in this population would amount to a clinical problem of considerable proportions. According to the National Osteoporosis Foundation, 44 million people (55% of the people over age 50) have either osteoporosis or low bone mass, and it is predicted that this number will increase to 52 million (35 million women) by the year 2010 (www.nof.org/advocacy/prevalence).
It is well recognized that fractures secondary to osteoporosis are accompanied by a reduction in psychological and physical well-being. As far as depression goes, it is difficult to know which came first, depression or fractures leading to subsequent depression. It has been reported that depressed people have a greater incidence of falls,2 and thus it is not unreasonable to consider that depression comes first in some people. Furthermore, depressed people are sedentary and eat poorly, factors that favor bone loss. The authors also speculate that increased cortisol levels associated with depression might lead to bone loss, similar to that observed with the pharmacologic administration of glucocorticoids. On the other hand, the current study, as well as a cohort study of American women, despite finding a link between depression and fractures, failed to detect an increase in depression associated with lower bone density measurements.2 However, other studies have reported increases in depression associated with lower bone densities.3-5
Bone loss has been documented in an established rodent model for stress-induced depression, characterized by a decrease in osteoblastic bone formation that can be attenuated by an antidepressant drug.6 In this experimental model, osteoblastic inhibition was mediated by stress-induced stimulation of the sympathetic nervous system. Although this response is associated with an increased secretion of adrenal glucocorticoids, the evidence also indicates a direct role for sympathetic fibers in bone.
There are several clinical lessons to be derived from these reports. Older, depressed women should be assessed for potential pharmacologic treatment to prevent osteoporosis-related fractures. We need to be aware that women who have experienced fractures may have depressive symptoms, and appropriate interventions can have a beneficial impact on quality of life. The important point is that depression and fractures are linked; one may precede the other and vice-versa in different patients.
References
1. Silverman SL, et al. Study. J Rheumatol. 2007;34:140-144.
2. Whooley MA, et al. Arch Intern Med. 1999;159:484-490.
3. Robbins J, et al. J Am Geriatr Soc. 2001;49:732-736.
4. Milliken LA, et al. J Gerontol A Biol Sci Med Sci. 2006;61:488-494.
5. Kahl KG, et al. Psychosom Med. 2006;68:669-674.
6. Yirmiya R, et al. Proc Natl Acad Sci. 2006; 103:16876-16881.
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