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Depressive vulnerability is not an independent risk factor for osteoporosis in postmenopausal women
Maturitas 33 (1999) 133 – 137 www.elsevier.com/locate/maturitas
Depressive vulnerability is not an independent risk factor for osteoporosis in postmenopausal women Jean Yves Reginster a,b,c,*, Rita Deroisy b, Isabelle Paul a, Michel Hansenne d, Marc Ansseau d a WHO Collaborating Center for Public Health Aspects of Osteoarticular Disorders, Department of Epidemiology and Public Health, Uni6ersity of Lie`ge, Batiment B23, CHU Sart Tilman, 4000 Lie`ge, Belgium b Bone and Cartilage Metabolism Unit, Uni6ersity of Lie`ge, Lie`ge, Belgium c Georgetown Uni6ersity Medical Center, Washington DC, USA d Department of Psychiatry and Medical Psychology, Uni6ersity of Lie`ge, Lie`ge, Belgium
Received 4 March 1999; accepted 23 July 1999
Abstract Major depression has been repeatedly but not consistently reported to be associated with low bone mineral density (BMD) and to an increased risk for fracture in women. We have investigated, in healthy postmenopausal women, whether depressive symptomatology, assessed by the General Health Questionnaire (GHQ), was associated to a significant decrease in BMD, hence supporting the hypothesis of an independent pathogenetic link between the two disorders. We investigated 121 postmenopausal women, aged 48 – 77 years, spontaneously attending a screening visit for osteoporosis in an outpatient facility. BMD of the spine and the non-dominant hip (total and neck areas) were measured by Dual Energy X-Ray absorptiometry. All subjects completed to the ‘General Health Questionnaire’ translated and validated in French. No significant correlations were observed between the GHQ score and BMD of the spine (P= 0.54), the total hip area (P= 0.65), or the femoral neck area (P= 0.65). No differences in terms of spinal or femoral BMD were observed between women with GHQ score B5 or ] 5. When comparing values of BMD between women within the upper and the lower quartiles for GHQ score, no difference was observed for spine (P= 0.69), total hip (P=0.80), or femoral neck (P =0.93). Similarly, GHQ scores were not significantly different when comparing women in the upper and lower quartiles of BMD distribution at the spine or the hip. In conclusion, notwithstanding the clinical pattern of postmenopausal osteoporosis can lead to depression and, on the other hand, hormonal and behavioral disturbances reported in depression might be enhancing factors for accelerated bone loss, our present results do not support the hypothesis that otherwise healthy postmenopausal women with increased depressive complaints are also more prone to exhibit osteoporotic fractures. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Bone mineral density; Depression; Mood; Osteoporosis
* Corresponding author. Tel.: + 32-4-3662501; fax: + 32-4-3662812. E-mail address: [email protected] (J.Y. Reginster) 0378-5122/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 8 - 5 1 2 2 ( 9 9 ) 0 0 0 5 7 - 2
134
J.Y. Reginster et al. / Maturitas 000 (1999) 000–000
1. Introduction
2. Material and methods
Osteoporosis is a disease characterized by low bone mass and micro-architectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk [1]. The most important cause of involutional osteoporosis in women is the bone loss that occurs after the menopause as a result of the withdrawal of endogenous estrogen secretion by the ovaries. The factors that determine, on an individual basis, the rate of bone loss after the menopause are not yet fully understood [2]. Major depression has been repeatedly [3–6] but not consistently [7] reported to be associated with low bone mineral density (BMD) of the spine and the hip and to an increased risk for fracture in women. However, it is not clear whether this potential association might be related to the psychiatric disorder by itself or to the hormonal disturbances or the nutritional abnormalities associated with depression. We have investigated, in healthy postmenopausal women, whether the presence of depressive complaints, assessed by the French version of the General Health Questionnaire (GHQ – 28) [8 – 10] was associated to a significant decrease in BMD, hence supporting the hypothesis of an independent pathogenetic link between the two disorders.
2.1. Patients We investigated 121 postmenopausal women, aged 48–77 years, spontaneously attending a screening visit for osteoporosis in an outpatient facility at the University of Lie`ge. These women had never been treated for osteoporosis. Subjects presenting disorders known to interfere with bone metabolism were excluded from the study. All subjects gave an informed consent to participate in the study which was previously approved by the I.R.B. of the University of Lie`ge.
2.2. Procedures BMD of the spine and the non-dominant hip (total and neck areas) were measured by Dual Energy X-Ray absorptiometry (DXA) (Hologic QDR 2000, Waltham, MA, USA), following previously described and validated procedures [11]. All subjects completed to the GHQ–28, [9] translated and validated in French [8,10]. This 28-item self-rating questionnaire covers four domains, i.e. depression, anxiety, somatic factors, and physical dysfunction leading to a total score (0–28) reflecting the presence of a depressive vulnerability in a nonpsychiatric individual depressive illness. A score above 5 is considered to be associated with an increased susceptibility to later develop a depression [9–11].
2.3. Statistical analysis Table 1 Demographic characteristics of the study population, mean (SEM) Age (years) Time from menopause (years) Weight (kg) Height (cm) GHQ-28 score Spinal BMD (g/cm2) Total hip BMD (g/cm2) Femoral neck BMD (g/cm2) ERT/HRT users (%)
63.4 (0.6) 15.4 (0.8) 66.9 (1.2) 160.0 (0.5) 10.7 (0.6) 0.91 (0.01) 0.78 (0.01) 0.68 (0.01) 36.3
The possible relationship between BMD values and the GHQ score was investigated by multiple analysis of variance (MANOVA) after standardization for age, time from menopause, weight, height, and estrogen replacement therapy (ERT) use. Spinal and hip BMD were compared in women with GHQ score B 5 and \5 as well as in the lowest and highest quartiles of the GHQ distribution by means of an exact Fisher’s test. GHQ scores were also compared between the lowest and highest quartiles of the BMD distribution at the spine or at the hip level.
J.Y. Reginster et al. / Maturitas 33 (1999) 133–137
135
Table 2 Duration of hormone replacement therapy in our population of estrogens users (n = 44)
N
Less than 1 year
More than 1 year less than 5 years
More than 5 years
6
9
29
3. Results Characteristics of the study population are summarized in Table 1. Duration of hormone replacement therapy in our population of estrogen users is summarized in Table 2. No significant correlations were observed between the GHQ score and BMD of the spine (P =0.54), of the total hip area (P =0.65), or of the femoral neck area (P =0.65). 98/121 (87.5%) of the studied population presented a GHQ score =5. ERT use was equally distributed in the two subsets of the population. GHQ scores were not statistically different in women treated [10.31 (SEM 1.02)] (n = 44) with ERT or unsupplemented [10.83 (SEM 0.73)] (n= 77) (P= 0.60). No differences in terms of spinal or femoral BMD were observed between women with GHQ score B 5 or \5 (Table 3). When comparing values of BMD between women within the upper and the lower quartiles for GHQ score, no difference was observed for spine (P = 0.69), total hip (P=0.80), or femoral neck (P = 0.93). Similarly, GHQ scores were not significantly different when comparing women in the upper and lower quartiles of BMD distribution at the spine or the hip (Table 4). Finally, no significant relationship existed between the BMD parameters and any of the four GHQ subscores specifically related to depression, anxiety, somatic factors, and physical dysfunction (Table 5).
4. Discussion The values of spinal and hip BMD measured in the present study are in accordance with the published normative ranges for healthy Belgian postmenopausal women [11]. Similarly, the distribution of GHQ score fits with previous reports of mood assessment in a similar population [12]. In the present study, we do not report any
significant correlation between BMD of the spine or the hip and the value of GHQ obtained from a cohort of otherwise healthy postmenopausal Caucasian women. GHQ is not a scale aiming at the diagnosis of established depression, but a tool allowing the early detection of mood disturbances which indicates a higher probability for an individual to later develop the full presentation of a depression. Similarly, BMD assessment is considered the single best predictive factor for the future risk of postmenopausal women to later develop osteoporotic fractures [2]. Thus, the objective of our investigation was not to directly assess the co-morbidity between depression and osteoporosis in postmenopausal women but rather to investigate whether those women with the highest probability to develop a depressive pattern were also the most prone to later exhibit osteoporosis-related fractures. This can easily explain the discrepancy between our Table 3 Bone mineral density (g/cm2) [mean (SEM)] at different regions of interest (ROI) in women with GHQ-28 score below and above 5 ROI
GHQB5
GHQ\5
P value
Spine Total hip Femoral neck
0.921 (0.01) 0.821 (0.01) 0.710 (0.01)
0.905 (0.02) 0.776 (0.01) 0.677 (0.01)
0.67 0.11 0.17
Table 4 GHQ-28 scores [mean (SEM)] in women within the lowest and the highest quartiles of bone mineral density distribution at different regions of interest (ROI) ROI
Lowest quartile
Highest quartile
P value
Spine Total hip Femoral neck
10.54 (0.5) 10.36 (0.6) 11.32 (0.5)
10.74 (0.6) 10.72 (0.6) 10.51 (0.6)
0.87 0.84 0.58
J.Y. Reginster et al. / Maturitas 000 (1999) 000–000
136
Table 5 Correlation between Bone mineral density and GHQ subscores in women [r(p)]
Spine Total hip Femoral neck
Depression
Anxiety
Somatic factors
Physical dysfunction
−0.00 (0.99) −0.08 (0.39) −0.05 (0.58)
−0.05 (0.62) −0.04 (0.69) −0.06 (0.53)
0.07 (0.46) −0.04 (0.69) −0.22 (0.81)
0.17 (0.56) 0.01 (0.51) −0.01 (0.79)
results and other colleagues who reported decreased BMD [3–5] or increased fracture rates [6] in elderly patients with severe depression. Established depression is associated with several endocrine disturbances including hypercortisolism, hypothalamic hypogonadism, and anorexia [4]. Nutritional abnormalities and hypodynamism are also common features of depressed postmenopausal women. All these problems, by themselves, can be considered as independent risk factors for bone loss and osteoporosis [2,11]. Similarly, even if no association were found between lifetime anti-depressant drug treatment and bone density [4], anticonvulsant drugs (e.g. carbamazepin and valproı¨c acid) that are sometimes used in the treatment of depression were associated with lower BMD values [13]. This also can explain the results observed in studies involving depressive women with long-term treatment. On the other hand, in established osteoporosis, chronic pain, limitation of functional ability, and decrease in self-esteem were consistently reported, hence leading to severe impairment in quality of life perception, all elements favoring the development of depression in elderly women [14,15]. However, when BMD of the spine and hip were measured in a large population-based sample of elderly men and women, with almost no clinical depression (1.5%), no correlation were found with mood disturbances, assessed by the Beck Depression Inventory, in accordance with our present results [7]. One could be surprised that GHQ score are not significantly lower in women receiving ERT, since ERT and HRT are widely accepted as positively influencing the quality of life and subsequent mood of healthy postmenopausal women [16,17]. However, in the present study, we only recorded the presence or absence of ERT without assessing
the nature of the substitutive hormone, the dose, the regimen, the duration or the compliance to treatment. This prevents to draw any conclusion on this particular issue. In conclusion, notwithstanding the clinical pattern of postmenopausal osteoporosis can lead to depression and, on the other hand, hormonal and behavioral disturbances reported in depression might be enhancing factors for accelerated bone loss, our present results do not support the hypothesis that otherwise healthy postmenopausal women with increased probability to later develop a depression are also more prone to exhibit osteoporotic fractures.
References [1] Consensus development conference. Diagnosis, prophylaxis and treatment of osteoporosis, Am J Med 1991;90:107 – 110. [2] Assessment of fracture risk and its application to screening for postmenopausal osteoporosis, WHO Technical Report Series, 1994, 843, ISBN 92 4 1208430. [3] Schweiger U, Deuschle M, Korner A, Lammers CH, Schmider J, Gotthardt U, et al. Low lumbar bone mineral density in patients with major depression. Am J Psychiatry 1994;151:1691 – 3. [4] Michelson D, Stratakis C, Hill L, Reynolds J, Galliven E, Chrousos G, et al. Bone mineral density in women with depression. N Engl J Med 1996;335:1176– 81. [5] Halbreich U, Rojansky N, Palter S, Hreschchyshyn M, Kreeger J, Bakhai Y, et al. Decreased bone mineral density in medicated psychiatric patients. Psychosom Med 1995;57:485 – 91. [6] Whooley MA, Cauley JA, Nevitt MC, Ensrud K, Browner WS. Depression is associated with low bone density and fracture in older women. J Bone Miner Res 1997;12S1:S172. [7] Kritz-Silverstein D, Barrett-Connor E. Depressed mood and bone mineral density in older men and women: The Rancho Bernardo Study. J Bone Miner Res 1997;12S1:S251.
J.Y. Reginster et al. / Maturitas 33 (1999) 133–137 [8] Bologni M, Bettshart W, Zehndergubler M, Rossier L. The validity of the French version of the GHQ-28 and PSYDIS in a community sample of 20 years olds in Switzerland. Eur Arch Psychiatr Neurol Sci 1989;238:161 – 8. [9] Goldberg DP. The Detection of Psychiatric Illness by Questionnaire. Mansley monograph, 1972, 21, Oxford University Press (Publ.). [10] Pariente P, Challita H, Mesbah M, Guelfy JD. The GHQ-28 questionnaire in French: a validation survey. Eur Psych 1992;7:15–20. [11] Reginster J.Y. Oste´oporose me´nopausique: Traitement prophylactique. Masson, 1993, ISBN: 2-225-84221-3. [12] Ansseau M. La de´pression de la personne aˆge´e. Rev Med Lie`ge 1997;52:262 – 6. [13] Jones G, Sambrook PN. Drug-induced disorders of bone metabolism: incidence, management and avoidance. Drug Saf 1994;10:480 – 9.
.
137
[14] Lydicke E, Zimmerman S, Yawn B, Love B, Kleerekoper M, Ross P, Martin A, Holmes R. Development and validation of a discriminate quality of life questionnaire for osteoporosis (The OPTQoL). JBMR 1997;12:456 – 63. [15] Cook D, Guyatt G, Adachi J, Clifton J, Griffith L, Epstein R, et al. Quality of life issues in women with vertebral fractures due to osteoporosis. Arthritis Rheum 1993;36:750 – 6. [16] Reginster JY, Zartarian M, Colau JC. Influence de l’association du nome´gestrol ace´tate sur l’ame´lioration de la qualite´ de vie induite par une estroge´nothe´rapie chez la femme me´nopause´e. Contraception, Fertilite´ Sexualite´ 1996;24:847 – 51. [17] Wiklund I, Berg G, Hammar M, Karlberg J, Lindgren R, Sandin K. Long-term effect of transdermal hormonal therapy on aspects of quality of life in postmenopausal women. Maturitas 1992;14:225 – 36.
Depressive vulnerability is not an independent risk factor for osteoporosis in postmenopausal women Jean Yves Reginster a,b,c,*, Rita Deroisy b, Isabelle Paul a, Michel Hansenne d, Marc Ansseau d a WHO Collaborating Center for Public Health Aspects of Osteoarticular Disorders, Department of Epidemiology and Public Health, Uni6ersity of Lie`ge, Batiment B23, CHU Sart Tilman, 4000 Lie`ge, Belgium b Bone and Cartilage Metabolism Unit, Uni6ersity of Lie`ge, Lie`ge, Belgium c Georgetown Uni6ersity Medical Center, Washington DC, USA d Department of Psychiatry and Medical Psychology, Uni6ersity of Lie`ge, Lie`ge, Belgium
Received 4 March 1999; accepted 23 July 1999
Abstract Major depression has been repeatedly but not consistently reported to be associated with low bone mineral density (BMD) and to an increased risk for fracture in women. We have investigated, in healthy postmenopausal women, whether depressive symptomatology, assessed by the General Health Questionnaire (GHQ), was associated to a significant decrease in BMD, hence supporting the hypothesis of an independent pathogenetic link between the two disorders. We investigated 121 postmenopausal women, aged 48 – 77 years, spontaneously attending a screening visit for osteoporosis in an outpatient facility. BMD of the spine and the non-dominant hip (total and neck areas) were measured by Dual Energy X-Ray absorptiometry. All subjects completed to the ‘General Health Questionnaire’ translated and validated in French. No significant correlations were observed between the GHQ score and BMD of the spine (P= 0.54), the total hip area (P= 0.65), or the femoral neck area (P= 0.65). No differences in terms of spinal or femoral BMD were observed between women with GHQ score B5 or ] 5. When comparing values of BMD between women within the upper and the lower quartiles for GHQ score, no difference was observed for spine (P= 0.69), total hip (P=0.80), or femoral neck (P =0.93). Similarly, GHQ scores were not significantly different when comparing women in the upper and lower quartiles of BMD distribution at the spine or the hip. In conclusion, notwithstanding the clinical pattern of postmenopausal osteoporosis can lead to depression and, on the other hand, hormonal and behavioral disturbances reported in depression might be enhancing factors for accelerated bone loss, our present results do not support the hypothesis that otherwise healthy postmenopausal women with increased depressive complaints are also more prone to exhibit osteoporotic fractures. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Bone mineral density; Depression; Mood; Osteoporosis
* Corresponding author. Tel.: + 32-4-3662501; fax: + 32-4-3662812. E-mail address: [email protected] (J.Y. Reginster) 0378-5122/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 8 - 5 1 2 2 ( 9 9 ) 0 0 0 5 7 - 2
134
J.Y. Reginster et al. / Maturitas 000 (1999) 000–000
1. Introduction
2. Material and methods
Osteoporosis is a disease characterized by low bone mass and micro-architectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk [1]. The most important cause of involutional osteoporosis in women is the bone loss that occurs after the menopause as a result of the withdrawal of endogenous estrogen secretion by the ovaries. The factors that determine, on an individual basis, the rate of bone loss after the menopause are not yet fully understood [2]. Major depression has been repeatedly [3–6] but not consistently [7] reported to be associated with low bone mineral density (BMD) of the spine and the hip and to an increased risk for fracture in women. However, it is not clear whether this potential association might be related to the psychiatric disorder by itself or to the hormonal disturbances or the nutritional abnormalities associated with depression. We have investigated, in healthy postmenopausal women, whether the presence of depressive complaints, assessed by the French version of the General Health Questionnaire (GHQ – 28) [8 – 10] was associated to a significant decrease in BMD, hence supporting the hypothesis of an independent pathogenetic link between the two disorders.
2.1. Patients We investigated 121 postmenopausal women, aged 48–77 years, spontaneously attending a screening visit for osteoporosis in an outpatient facility at the University of Lie`ge. These women had never been treated for osteoporosis. Subjects presenting disorders known to interfere with bone metabolism were excluded from the study. All subjects gave an informed consent to participate in the study which was previously approved by the I.R.B. of the University of Lie`ge.
2.2. Procedures BMD of the spine and the non-dominant hip (total and neck areas) were measured by Dual Energy X-Ray absorptiometry (DXA) (Hologic QDR 2000, Waltham, MA, USA), following previously described and validated procedures [11]. All subjects completed to the GHQ–28, [9] translated and validated in French [8,10]. This 28-item self-rating questionnaire covers four domains, i.e. depression, anxiety, somatic factors, and physical dysfunction leading to a total score (0–28) reflecting the presence of a depressive vulnerability in a nonpsychiatric individual depressive illness. A score above 5 is considered to be associated with an increased susceptibility to later develop a depression [9–11].
2.3. Statistical analysis Table 1 Demographic characteristics of the study population, mean (SEM) Age (years) Time from menopause (years) Weight (kg) Height (cm) GHQ-28 score Spinal BMD (g/cm2) Total hip BMD (g/cm2) Femoral neck BMD (g/cm2) ERT/HRT users (%)
63.4 (0.6) 15.4 (0.8) 66.9 (1.2) 160.0 (0.5) 10.7 (0.6) 0.91 (0.01) 0.78 (0.01) 0.68 (0.01) 36.3
The possible relationship between BMD values and the GHQ score was investigated by multiple analysis of variance (MANOVA) after standardization for age, time from menopause, weight, height, and estrogen replacement therapy (ERT) use. Spinal and hip BMD were compared in women with GHQ score B 5 and \5 as well as in the lowest and highest quartiles of the GHQ distribution by means of an exact Fisher’s test. GHQ scores were also compared between the lowest and highest quartiles of the BMD distribution at the spine or at the hip level.
J.Y. Reginster et al. / Maturitas 33 (1999) 133–137
135
Table 2 Duration of hormone replacement therapy in our population of estrogens users (n = 44)
N
Less than 1 year
More than 1 year less than 5 years
More than 5 years
6
9
29
3. Results Characteristics of the study population are summarized in Table 1. Duration of hormone replacement therapy in our population of estrogen users is summarized in Table 2. No significant correlations were observed between the GHQ score and BMD of the spine (P =0.54), of the total hip area (P =0.65), or of the femoral neck area (P =0.65). 98/121 (87.5%) of the studied population presented a GHQ score =5. ERT use was equally distributed in the two subsets of the population. GHQ scores were not statistically different in women treated [10.31 (SEM 1.02)] (n = 44) with ERT or unsupplemented [10.83 (SEM 0.73)] (n= 77) (P= 0.60). No differences in terms of spinal or femoral BMD were observed between women with GHQ score B 5 or \5 (Table 3). When comparing values of BMD between women within the upper and the lower quartiles for GHQ score, no difference was observed for spine (P = 0.69), total hip (P=0.80), or femoral neck (P = 0.93). Similarly, GHQ scores were not significantly different when comparing women in the upper and lower quartiles of BMD distribution at the spine or the hip (Table 4). Finally, no significant relationship existed between the BMD parameters and any of the four GHQ subscores specifically related to depression, anxiety, somatic factors, and physical dysfunction (Table 5).
4. Discussion The values of spinal and hip BMD measured in the present study are in accordance with the published normative ranges for healthy Belgian postmenopausal women [11]. Similarly, the distribution of GHQ score fits with previous reports of mood assessment in a similar population [12]. In the present study, we do not report any
significant correlation between BMD of the spine or the hip and the value of GHQ obtained from a cohort of otherwise healthy postmenopausal Caucasian women. GHQ is not a scale aiming at the diagnosis of established depression, but a tool allowing the early detection of mood disturbances which indicates a higher probability for an individual to later develop the full presentation of a depression. Similarly, BMD assessment is considered the single best predictive factor for the future risk of postmenopausal women to later develop osteoporotic fractures [2]. Thus, the objective of our investigation was not to directly assess the co-morbidity between depression and osteoporosis in postmenopausal women but rather to investigate whether those women with the highest probability to develop a depressive pattern were also the most prone to later exhibit osteoporosis-related fractures. This can easily explain the discrepancy between our Table 3 Bone mineral density (g/cm2) [mean (SEM)] at different regions of interest (ROI) in women with GHQ-28 score below and above 5 ROI
GHQB5
GHQ\5
P value
Spine Total hip Femoral neck
0.921 (0.01) 0.821 (0.01) 0.710 (0.01)
0.905 (0.02) 0.776 (0.01) 0.677 (0.01)
0.67 0.11 0.17
Table 4 GHQ-28 scores [mean (SEM)] in women within the lowest and the highest quartiles of bone mineral density distribution at different regions of interest (ROI) ROI
Lowest quartile
Highest quartile
P value
Spine Total hip Femoral neck
10.54 (0.5) 10.36 (0.6) 11.32 (0.5)
10.74 (0.6) 10.72 (0.6) 10.51 (0.6)
0.87 0.84 0.58
J.Y. Reginster et al. / Maturitas 000 (1999) 000–000
136
Table 5 Correlation between Bone mineral density and GHQ subscores in women [r(p)]
Spine Total hip Femoral neck
Depression
Anxiety
Somatic factors
Physical dysfunction
−0.00 (0.99) −0.08 (0.39) −0.05 (0.58)
−0.05 (0.62) −0.04 (0.69) −0.06 (0.53)
0.07 (0.46) −0.04 (0.69) −0.22 (0.81)
0.17 (0.56) 0.01 (0.51) −0.01 (0.79)
results and other colleagues who reported decreased BMD [3–5] or increased fracture rates [6] in elderly patients with severe depression. Established depression is associated with several endocrine disturbances including hypercortisolism, hypothalamic hypogonadism, and anorexia [4]. Nutritional abnormalities and hypodynamism are also common features of depressed postmenopausal women. All these problems, by themselves, can be considered as independent risk factors for bone loss and osteoporosis [2,11]. Similarly, even if no association were found between lifetime anti-depressant drug treatment and bone density [4], anticonvulsant drugs (e.g. carbamazepin and valproı¨c acid) that are sometimes used in the treatment of depression were associated with lower BMD values [13]. This also can explain the results observed in studies involving depressive women with long-term treatment. On the other hand, in established osteoporosis, chronic pain, limitation of functional ability, and decrease in self-esteem were consistently reported, hence leading to severe impairment in quality of life perception, all elements favoring the development of depression in elderly women [14,15]. However, when BMD of the spine and hip were measured in a large population-based sample of elderly men and women, with almost no clinical depression (1.5%), no correlation were found with mood disturbances, assessed by the Beck Depression Inventory, in accordance with our present results [7]. One could be surprised that GHQ score are not significantly lower in women receiving ERT, since ERT and HRT are widely accepted as positively influencing the quality of life and subsequent mood of healthy postmenopausal women [16,17]. However, in the present study, we only recorded the presence or absence of ERT without assessing
the nature of the substitutive hormone, the dose, the regimen, the duration or the compliance to treatment. This prevents to draw any conclusion on this particular issue. In conclusion, notwithstanding the clinical pattern of postmenopausal osteoporosis can lead to depression and, on the other hand, hormonal and behavioral disturbances reported in depression might be enhancing factors for accelerated bone loss, our present results do not support the hypothesis that otherwise healthy postmenopausal women with increased probability to later develop a depression are also more prone to exhibit osteoporotic fractures.
References [1] Consensus development conference. Diagnosis, prophylaxis and treatment of osteoporosis, Am J Med 1991;90:107 – 110. [2] Assessment of fracture risk and its application to screening for postmenopausal osteoporosis, WHO Technical Report Series, 1994, 843, ISBN 92 4 1208430. [3] Schweiger U, Deuschle M, Korner A, Lammers CH, Schmider J, Gotthardt U, et al. Low lumbar bone mineral density in patients with major depression. Am J Psychiatry 1994;151:1691 – 3. [4] Michelson D, Stratakis C, Hill L, Reynolds J, Galliven E, Chrousos G, et al. Bone mineral density in women with depression. N Engl J Med 1996;335:1176– 81. [5] Halbreich U, Rojansky N, Palter S, Hreschchyshyn M, Kreeger J, Bakhai Y, et al. Decreased bone mineral density in medicated psychiatric patients. Psychosom Med 1995;57:485 – 91. [6] Whooley MA, Cauley JA, Nevitt MC, Ensrud K, Browner WS. Depression is associated with low bone density and fracture in older women. J Bone Miner Res 1997;12S1:S172. [7] Kritz-Silverstein D, Barrett-Connor E. Depressed mood and bone mineral density in older men and women: The Rancho Bernardo Study. J Bone Miner Res 1997;12S1:S251.
J.Y. Reginster et al. / Maturitas 33 (1999) 133–137 [8] Bologni M, Bettshart W, Zehndergubler M, Rossier L. The validity of the French version of the GHQ-28 and PSYDIS in a community sample of 20 years olds in Switzerland. Eur Arch Psychiatr Neurol Sci 1989;238:161 – 8. [9] Goldberg DP. The Detection of Psychiatric Illness by Questionnaire. Mansley monograph, 1972, 21, Oxford University Press (Publ.). [10] Pariente P, Challita H, Mesbah M, Guelfy JD. The GHQ-28 questionnaire in French: a validation survey. Eur Psych 1992;7:15–20. [11] Reginster J.Y. Oste´oporose me´nopausique: Traitement prophylactique. Masson, 1993, ISBN: 2-225-84221-3. [12] Ansseau M. La de´pression de la personne aˆge´e. Rev Med Lie`ge 1997;52:262 – 6. [13] Jones G, Sambrook PN. Drug-induced disorders of bone metabolism: incidence, management and avoidance. Drug Saf 1994;10:480 – 9.
.
137
[14] Lydicke E, Zimmerman S, Yawn B, Love B, Kleerekoper M, Ross P, Martin A, Holmes R. Development and validation of a discriminate quality of life questionnaire for osteoporosis (The OPTQoL). JBMR 1997;12:456 – 63. [15] Cook D, Guyatt G, Adachi J, Clifton J, Griffith L, Epstein R, et al. Quality of life issues in women with vertebral fractures due to osteoporosis. Arthritis Rheum 1993;36:750 – 6. [16] Reginster JY, Zartarian M, Colau JC. Influence de l’association du nome´gestrol ace´tate sur l’ame´lioration de la qualite´ de vie induite par une estroge´nothe´rapie chez la femme me´nopause´e. Contraception, Fertilite´ Sexualite´ 1996;24:847 – 51. [17] Wiklund I, Berg G, Hammar M, Karlberg J, Lindgren R, Sandin K. Long-term effect of transdermal hormonal therapy on aspects of quality of life in postmenopausal women. Maturitas 1992;14:225 – 36.