Research reportThe association between depressive and anxiety symptoms and bone mineral density in the general population: The HUNT Study
Introduction
The prevalence of osteoporosis, a global issue, is on the rise as a result of an ageing population and lifestyle factors such as tobacco smoking and inactivity (Lane, 2006). In the absence of interventions, the lifetime risk of osteoporotic fracture lies within the range of 40% to 50% in women and 13% to 22% in men (Dennison et al., 2006). In 2000, the estimated number of osteoporotic fractures worldwide was 9.0 million, with the greatest proportion occurring in women (61.0%) and in Europe (34.8%) (Johnell and Kanis, 2006).
Various risk factors have been identified for osteoporosis and fragility fracture (Pasco et al., 2006b, Samelson and Hannan, 2006). The accumulating evidence suggests certain psychiatric disorders including substance use disorders (Clark et al., 2003), anorexia nervosa (Jayasinghe et al., 2008) and schizophrenia (Halbreich, 2007, Meyer and Lehman, 2006) may yet be unappreciated risk factors for reduced bone mineral density (BMD). Furthermore, previous research has reported reduced bone mass in individuals with either clinical depression or depressive symptoms, however the results are inconclusive within community-based samples and longitudinal studies (Cizza et al., 2009b, Cizza et al., 2010, Williams et al., 2009b). It is possible that these discrepancies are due to different diagnostic tools and systems used to categorise the severity, type and nature of depression, size of study samples and sampling biases arising from diverse designs and recruitment strategies. Diminished BMD may be attributed to disease and medication related processes and/or modifiable lifestyle factors associated with psychopathology (Williams et al., 2009b). To date, there has been no research conducted investigating whether anxiety disorders or symptoms are associated with bone loss among community-dwelling adults, although osteoporosis has been shown to be a risk factor for generalised anxiety disorder (GAD) (Muhsen et al., 2008).
Depressive and anxiety disorders are highly prevalent; cross-national 12-month prevalence figures show between 0.8% to 9.6% and 2.4% to 18.2% suffer from depressive and anxiety symptoms that qualify for a clinical diagnosis, respectively (Demyttenaere et al., 2004). Further, depressive and anxiety disorders are highly co-morbid and share many etiological and pathophysiological features (Das-Munshi et al., 2008), which makes it plausible to assume a relationship may also exist between anxiety and BMD.
Given that low BMD might be disproportionately prevalent among individuals with depression and other psychiatric disorders (Williams et al., 2009b), and that anxiety is highly co-morbid with depression, we hypothesised that anxiety could also be a risk factor for reduced BMD. Thus, this epidemiological study aimed to investigate the cross-sectional and longitudinal relationships between current depressive and anxiety symptoms and BMD measures in adult men and women.
Section snippets
Study design and subjects
This study examined data collected from both men and women participating in the second Nord-Trondelag Health Study (HUNT 2, 1995–97). HUNT (http://www.ntnu.no/hunt/english) is a community-based survey of all residents aged over 19 years residing in Nord-Trondelag County, situated between 63 and 65° north in central Norway. Overall, 71.2% of the total population agreed to participate (n = 66,140). A detailed description of the study objectives, design and methodology are described elsewhere (Holmen
Depressive symptoms
One hundred and twenty-four men (124/1181, 10.5%) were identified with depressive symptoms. Those with depressive symptoms were younger, heavier, less likely to engage in light physical activity and have arthritis and were more likely to drink alcohol and use antidepressant medication. No differences were detected in height, unadjusted distal and ultradistal forearm BMD, history of hyperthyroidism, smoking status, hard physical activity, tea and coffee intake and use of corticosteroids between
Discussion
Cross-sectional data from this study supports the hypothesis that current depressive as well as anxiety symptoms are associated with reduced BMD. Among men, BMD was 2.6% lower at the ultradistal forearm and tended to be lower at the distal forearm for those with depressive symptoms and 2.0% and 2.6% lower at the distal and ultradistal forearm for those with anxiety symptoms. Among women with depressive symptoms, BMD was reduced at the distal and ultradistal forearm for heavier women compared to
Role of funding source
The study was funded by grants from the Norwegian Women's Public Health Association, the Norwegian Osteoporosis Foundation, Norwegian Research Council and AstraZeneca Norway.
The funding providers played no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Conflict of interests
Lana Williams and Julie Pasco have received research support from an unrestricted educational grant from Eli Lilly.
Ottar Bjerkeset, Margaret Henry, Berit Schei and Siri Forsmo have no conflicts of interest in the study including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript.
Arnulf Langhammer has been the leader of the Lung Study in HUNT. The Lung Study was funded by unrestricted grants from AstraZeneca
Acknowledgments
Nord-Trøndelag Health Study (The HUNT Study) is a collaboration between HUNT Research Centre, Faculty of Medicine at the Norwegian University of Science and Technology (NTNU, Verdal), Norwegian Institute of Public Health and Nord-Trøndelag County Council.
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