Bone mineral density in women with depression

Allostasis: A Theoretical Framework for Understanding and Evaluating Perinatal Health Outcomes

OBJECTIVE

To explore the theory of allostasis within the context of childbearing women's perceptions or experiences of stress and perinatal health outcomes.

DATA SOURCES

Articles published in refereed journals and selected chapters from published books that addressed physiological and psychological effects of perceived or actual stress experiences, or both, including the theory of allostasis, on health outcomes.

STUDY SELECTION

Qualitative, quantitative, and review articles that focused on psychoneurohormonal responses to physical and psychological stress in pregnant and nonpregnant human cohorts and the theory of allostasis.

DATA EXTRACTION AND SYNTHESIS

The impact of abnormal allostatic states in childbearing women in response to physiological and psychological perceptions or experiences of stress, or both was analyzed. There is a growing body of epidemiologic evidence to support the relationship between maternal stress and adverse pregnancy outcomes.

CONCLUSIONS

The theory of allostasis provides a framework for understanding and evaluating the complex elements of stress, coping, and adaptation during childbearing on perinatal health outcomes and has the potential to provide new insight into previously unexplained adverse perinatal events.

Depressive symptoms as a risk factor for osteoporosis and fractures in older Mexican American women

INTRODUCTION AND HYPOTHESIS

Despite higher rates of depression, lower hormone replacement therapy (HRT) use, and inadequate knowledge of factors associated with osteoporosis, Mexican Americans have been understudied with regards to the association between depression, osteoporosis, and fractures. We hypothesized that depression increases the risk for osteoporosis and fractures among older Mexican American women.

METHODS

Seven years of prospective data (1993-2001) from the Hispanic Established Populations for Epidemiologic Studies of the Elderly were analyzed for 1,350 women in the Southwest United States who had complete data for at least the first follow-up interview.

RESULTS

Respondents (mean age:75) were generally poorly educated, had low income, and reported poor or fair health. High levels of depressive symptoms were reported by 31%, while new diagnosis of osteoporosis and new fractures were reported by 18 and 13%, respectively. Logistic regression analyses showed that predictors of newly diagnosed osteoporosis included age, high school (HS) education, ever having been an alcoholic, early menopause, hormone replacement therapy, and high levels of depressive symptoms. Factors predictive of new fractures included age, HS education, diabetes, early menopause, and high levels of depressive symptoms.

CONCLUSIONS

Depressive symptoms were associated with increased risk of osteoporosis and new fractures, even after controlling for other predictive factors.

Onset of Depression in Elderly Persons After Hip Fracture: Implications for Prevention and Early Intervention of Late-Life Depression

OBJECTIVES

To identify predictors of onset of major depressive disorder (MDD) and of depressive symptoms in subjects who suffered a hip fracture.

DESIGN

Prospective naturalistic study.

SETTING

University of Pittsburgh Medical Center-Shadyside, a large urban hospital in Pittsburgh, Pennsylvannia.

PARTICIPANTS

One hundred twenty-six elderly patients who received surgical fixation for hip fracture and who were not experiencing a major depressive episode at the time of the fracture; severely cognitively impaired persons were excluded.

MEASUREMENTS

Subjects were evaluated at the time of hospital discharge using a battery of clinical measures (including apathy measured using the Apathy Evaluation Scale (AES), delirium, cognitive measures, social support, and disability level). Depression was assessed at the end of the surgical stay, 2 weeks later, and then monthly for 6 months, using the Hamilton Rating Scale for Depression (Ham-D) to evaluate symptomatology and the Primary Care Evaluation of Mental Disorders to evaluate diagnosis of MDD.

RESULTS

Eighteen of 126 subjects (14.3%) developed MDD after hip fracture. Of these, 11 developed MDD by the end of the hospitalization, and seven developed MDD between 2 and 10 weeks later. Logistic regression showed that baseline apathy score, as measured using the AES, was the only clinical measure associated with the development of MDD (odds ratio=1.09, 95% confidence interval=1.03-1.16, P=.003); 46.2% of those with high AES scores developed MDD, versus 10.9% of those with lower scores. In contrast, cognitive variables, delirium, disability after hip fracture, and other factors related to the fracture (e.g., fracture type) were not associated with MDD. A repeated-measures analysis with Ham-D over time as a dependent variable generally confirmed these findings; depressive symptoms were highest immediately after the fracture, and apathy and delirium scores were associated with higher depressive symptom levels.

CONCLUSION

The onset of MDD is common after hip fracture, and the greatest period of risk is immediately after the fracture. Individuals with clinical evidence of apathy are at high risk for developing MDD, and evaluation and close follow-up of such individuals is warranted. However, further research is needed to examine other candidate variables (e.g., clinical measures or biomarkers) to model adequately the risk for MDD after hip fracture and other disabling medical events.

Osteoporosis and depression: a historical perspective

In the early 1980s, researchers studying osteoporosis noted that depression was one of the major negative consequences of bone loss and fractures. These researchers believed that osteoporosis and fractures occurred first, causing a reactive depression. Meanwhile, a similar but distinct psychiatry literature noted that osteoporosis or bone loss appeared to be an undesirable consequence of major depression. Here, depression was seen as the causal factor, and osteoporosis was the outcome. The psychiatric perspective is more biological, based on the presence of hypercorticoidism in depressed individuals. Those who believe that osteoporosis leads to depression point out that depression is a consequence of many chronic illnesses. Regardless of the correct causal order, the strong positive relationship between osteoporosis and depression merits further clinical and research attention in the future.

Depression induces bone loss through stimulation of the sympathetic nervous system

Major depression is associated with low bone mass and increased incidence of osteoporotic fractures. However, causality between depression and bone loss has not been established. Here, we show that mice subjected to chronic mild stress (CMS), an established model of depression in rodents, display behavioral depression accompanied by impaired bone mass and structure, as portrayed by decreases in trabecular bone volume density, trabecular number, and trabecular connectivity density assessed in the distal femoral metaphysis and L3 vertebral body. Bone remodeling analysis revealed that the CMS-induced skeletal deficiency is accompanied by restrained bone formation resulting from reduced osteoblast number. Antidepressant therapy, which prevents the behavioral responses to CMS, completely inhibits the decrease in bone formation and markedly attenuates the CMS-induced bone loss. The depression-triggered bone loss is associated with a substantial increase in bone norepinephrine levels and can be blocked by the beta-adrenergic antagonist propranolol, suggesting that the sympathetic nervous system mediates the skeletal effects of stress-induced depression. These results define a linkage among depression, excessive adrenergic activity, and reduced bone formation, thus demonstrating an interaction among behavioral responses, the brain, and the skeleton, which leads to impaired bone structure. Together with the common occurrence of depression and bone loss in the aging population, the present data implicate depression as a potential major risk factor for osteoporosis and the associated increase in fracture incidence.

Bone mineral density, bone turnover, and osteoprotegerin in depressed women with and without borderline personality disorder

OBJECTIVE

Low bone mineral density has repeatedly been reported in patients with major depressive disorder (MDD), and MDD has been discussed as a risk factor for the development of osteoporosis. MDD in young adults often occurs in the context of borderline personality disorder (BPD), and both MDD and BPD have been associated with a dysregulation of the hypothalamic-pituitary-adrenal system and subsequent hypercortisolemia. To date, it is unclear whether comorbid BPD in depressed patients modulates the extent of bone mass reduction. Therefore, we examined bone density, markers of bone turnover, and proinflammatory cytokines in depressed patients with and without BPD. Patients with BPD alone and healthy women served as comparison groups.

METHOD

Twenty-four patients with MDD and 23 patients with comorbid MDD and BPD were included. Sixteen patients with BPD and 20 healthy women of similar body mass index served as the comparison group. BMD was assessed by means of dual-energy x-ray absorptiometry. Markers of bone turnover, endocrine and immune parameters were determined. For data analysis, the group of depressed patients without comorbid BPD was divided according to age into two groups (younger depressed patients with a mean age of 30 years and older patients with a mean age of 42.9 years).

RESULTS

BMD at the lumbar spine was significantly reduced in a) depressed women with comorbid BPD (mean age, 28.6 years) and in b) older depressed patients without BPD (mean age, 42.9 years). Osteocalcin, a marker of osteoblastic activity, and crosslaps, a marker of bone loss, were significantly different between the study groups. Tumor necrosis factor-alpha was increased in depressed patients when compared with healthy women. Furthermore, TNF-alpha was positively correlated with serum crosslaps, a marker for osteoclastic activity.

CONCLUSION

Depression is associated with reduced bone mass, in particular in patients with comorbid BPD. Possible factors contributing to BMD reduction include endocrine and immune alterations associated with either MDD or BPD. We conclude from our data that a history of MDD with and without comorbid BPD should be considered as a risk factor in clinical assessment instruments for the identification of persons prone to osteoporosis.

Relationship between health-related quality of life domains and bone status in postmenopausal Japanese women

OBJECTIVE

To assess the relationship between health-related quality of life domains and bone status, including bone metabolism, in postmenopausal Japanese community women.

DESIGN

The study subjects were 88 women who were participants in a screening program for osteoporosis in 2003 without a history of mental disorders, metabolic disorders, smoking, bone fractures, and/or estrogen treatment. The participation rate was 75.9%. The age range was 50 to 68 years (mean, 57), and body mass index (BMI) ranged from 15.7 to 36.6 (mean, 22.4). Health-related quality of life domains were evaluated using the Medical Outcomes Study Short-Form 36 Health Survey, and bone mineral content was measured by quantitative ultrasound of the calcaneus. Serum total osteocalcin and serum N-telopeptide were measured by enzyme-linked immunosorbent assay. Multiple linear regression models were used to study the association of age, BMI, and eight health-related quality of life domains as independent variables in age-corrected bone status and markers of bone turnover as dependent ones.

RESULTS

The participants' calcaneal Z scores by quantitative ultrasound ranged from -2.14 to 2.71. The mean Z score was -0.17 (-0.27, -0.07). Multiple regression analysis revealed that BMI (P < 0.05), physical function (P < 0.01), and role-emotional (role limitations caused by emotional problems) (P < 0.01) were factors in increasing bone mineral content. Also, a positive relationship was found between vitality (P < 0.01), social function (P < 0.05), and total osteocalcin.

CONCLUSIONS

Although causality is not clear, in addition to low BMI, role limitations due to poor emotional status and low physical function are related to low bone mineral content in postmenopausal Japanese community women. These results imply that when we are concerned about osteoporosis in postmenopausal women, we should pay attention not only to their physical function but also to their psychological state.

Depressive symptoms and changes in body weight exert independent and site-specific effects on bone in postmenopausal women exercising for 1 year

BACKGROUND

Lower bone mineral density (BMD) has been documented in clinically depressed populations, and depression is the second most common chronic medical condition in general medical practice. Therefore, the purpose of this study was to determine whether depressive symptoms, vitality, and body weight changes were related to 1-year BMD changes after accounting for covariates.

METHODS

Healthy postmenopausal women (n=320; 40-65 years) were recruited, and 266 women completed the study. Participants were 3-10 years postmenopausal, sedentary, and either taking hormone replacement therapy (1-3.9 years) or not taking it (at least 1 year). Exclusion criteria were: current smoking status, history of fractures, low BMD, body mass index>32.9 or <19.0, or use of bone altering medications. Regional BMD was measured from dual-energy x-ray absorptiometry at baseline and 1 year. Self-reported depressive symptoms and vitality were measured using standard questionnaires.

RESULTS

Both the vitality and depressive symptoms scores were related to BMD changes at the femur neck but not at the greater trochanter or spine. Weight change was a predictor of BMD changes in the trochanter and spine but not in the femoral neck. Weight change and vitality and/or depressive symptoms had differential and site-specific effects on BMD changes at the hip. Vitality and depressive symptoms related to femoral neck changes and weight change related to greater trochanter changes.

CONCLUSIONS

The negative impact of depressive symptoms on BMD in this population of postmenopausal women was independent of body weight or other behavioral factors such as calcium compliance or exercise.

Depression, the perimenopause, and estrogen therapy

The focus of this chapter is the relationship between the onset of depression in women and the reproductive events of the perimenopause. The perimenopause is a time of considerable variability in reproductive function, which appears in some women to be associated with an increased susceptibility to depression. Elevated gonadotropin levels occur during the late perimenopause, with plasma follicle-stimulating hormone levels increasing in association with impaired ovarian function and decreased estradiol secretion. It is unclear, however, whether the variability in ovarian hormone secretion during the perimenopause has a substantial causal role in the development of depression. Epidemiologic studies have documented that most women do not become depressed during the menopausal transition. However, recent longitudinal studies suggest that in some women, perimenopause-related reproductive events play a role in the onset of depression. Additionally, randomized controlled trials have documented the short-term (3-6 weeks) antidepressant efficacy of estradiol in depressed perimenopausal women. Thus, although depression is not a uniform accompaniment of the menopausal transition, in some women age-related changes in ovarian estrogen production may alter central nervous system function and predispose them to develop depression.

Gender differences in depression and response to psychotropic medication

BACKGROUND

In the United States, depression is approximately twice as common among women as among men, across all age groups.

OBJECTIVE

This review examines gender differences in the epidemiology and clinical presentation of depression, and explores whether women respond differently than men to antidepressant medications.

METHODS

This is a selective review focusing on current issues in the management of depression, with particular attention to gender differences in the epidemiology, diagnosis, and treatment of the disease.

RESULTS

Women are more likely than men to have atypical symptoms of depression (eg, hypersomnia, hyperphagia), to have comorbid anxiety disorders, and to attempt suicide. Women are also more likely to have seasonal affective disorder. Mood and anxiety symptoms that seem to be related to the menstrual cycle do not often represent genuine premenstrual dysphoria, but when premenstrual dysphoric disorder does occur, its impact on quality of life is similar to that of major depressive disorder. There is ongoing controversy about whether men and women respond equally well to antidepressant medications, and preliminary evidence suggests that selective serotonin reuptake inhibitors (SSRIs) are more effective in the presence of estrogen. Depression affects about 10% of pregnant women. Antidepressant medication should be considered during pregnancy if depression is moderate or severe, or if withdrawal of maintenance medication is likely to result in recurrent depression. The potential benefits of using antidepressant medications in a pregnant or breastfeeding woman should be balanced against the potential risks to the newborn. Because of the risk of neonatal withdrawal syndrome, SSRIs should be used at the lowest effective dose during the third trimester of pregnancy and should be tapered before delivery.

CONCLUSIONS

Continuing research is needed to determine how gender influences the risk, clinical presentation, and response to treatment of depression. Exploration of sex differences in animals and humans should aid in efforts to treat depression as an organic disorder rather than a psychological maladaptation.

Multi-target strategies for the improved treatment of depressive states: Conceptual foundations and neuronal substrates, drug discovery and therapeutic application

Major depression is a debilitating and recurrent disorder with a substantial lifetime risk and a high social cost. Depressed patients generally display co-morbid symptoms, and depression frequently accompanies other serious disorders. Currently available drugs display limited efficacy and a pronounced delay to onset of action, and all provoke distressing side effects. Cloning of the human genome has fuelled expectations that symptomatic treatment may soon become more rapid and effective, and that depressive states may ultimately be "prevented" or "cured". In pursuing these objectives, in particular for genome-derived, non-monoaminergic targets, "specificity" of drug actions is often emphasized. That is, priority is afforded to agents that interact exclusively with a single site hypothesized as critically involved in the pathogenesis and/or control of depression. Certain highly selective drugs may prove effective, and they remain indispensable in the experimental (and clinical) evaluation of the significance of novel mechanisms. However, by analogy to other multifactorial disorders, "multi-target" agents may be better adapted to the improved treatment of depressive states. Support for this contention is garnered from a broad palette of observations, ranging from mechanisms of action of adjunctive drug combinations and electroconvulsive therapy to "network theory" analysis of the etiology and management of depressive states. The review also outlines opportunities to be exploited, and challenges to be addressed, in the discovery and characterization of drugs recognizing multiple targets. Finally, a diversity of multi-target strategies is proposed for the more efficacious and rapid control of core and co-morbid symptoms of depression, together with improved tolerance relative to currently available agents.

Depression and pain: an overview

BACKGROUND

Depression and pain are both burdensome ailments that affect a major proportion of the population. It is evident that depression and pain frequently coexist, with treatment and outcome implications.

OBJECTIVE

To review the literature on the nature, prevalence and co-morbidity of depression and pain, the biological and psychological mechanisms involved and treatment options, thus presenting a broad overview of the current information available.

METHODS

Relevant sources were identified from PubMed and Medline databases using a combination of keywords including depression, pain, prevalence, co-morbidity, biological and psychological mechanisms, serotonin (5-HT), norepinephrine (NE), hypothalamic-pituitary-adrenal (HPA) axis, amygdala, functional magnetic resonance imaging (fMRI), antidepressant and psychological therapy.

RESULTS

It is evident from the research that depression and pain are common co-morbidities. Pain as a physical symptom of depression affects approximately 65% of patients, leading to less favourable outcomes and greater health care utilization. Moreover, depression is a common feature in chronic pain patients and can affect pain threshold and tolerance. Evidence from biological and psychological studies has revealed mechanisms that link chronic pain to depression. Several classes of anti-depressants and psychological interventions have been used successfully in the treatment of somatic symptoms of depression and for a variety of pain syndromes.

CONCLUSIONS

Pain and depression are linked by overlapping phenomenology, neurobiology and therapy. They are mutually interacting, and the interaction has significant treatment and outcome implications.

Predictive factors of irritable bowel syndrome improvement: 1-year prospective evaluation in 400 patients

BACKGROUND

The natural history of the irritable bowel syndrome is poorly understood.

AIM

To assess the clinical course of the irritable bowel syndrome and the factors that might predict it.

METHODS

An observational prospective study, involving 400 irritable bowel syndrome patients meeting Rome II criteria. Symptoms were recorded in a diary over four non-consecutive months (1, 4, 7 and 10). Demographic data, associated disorders, psychological status and health-related quality of life were obtained.

RESULTS

At 1-year follow-up, half of the patients and half of their physicians considered irritable bowel syndrome to have improved, but improvement was minor. Diary data showed that, according to the type of symptom, improvement was small and quite different: diarrhoea in 19% of patients, abdominal pain frequency in 26%, constipation in 33% and abdominal pain intensity in 60%. Factors related to improvement at one year were: severe symptoms and poor health-related quality of life at first visit, irritable bowel syndrome-constipation, good improvement at 3 months, anxiety/depression, stress, symptoms related to meals and absence of comorbidity. By multivariate logistic regression, predictors were: severe basal symptoms and good improvement at 3 months (OR:CI 95%, 1.32:1.09-1.59 and 4.44:2.81-7.05).

CONCLUSIONS

At 1-year follow-up, half the patients and their physicians considered the irritable bowel syndrome to have had some improvement but, symptom diaries demonstrated that improvement was small and heterogeneous. Severe basal symptoms and improvement at 3 months were related to better prognosis.

HIV infection and bone mineral density in middle-aged women

BACKGROUND

Osteopenia is prevalent in persons with human immunodeficiency virus (HIV) infection and is part of a normal sequence of aging in women. Most studies of bone mineral density (BMD) and HIV infection have focused on men or have lacked a comparison group of individuals without HIV infection with similar behavioral risk factors.

METHODS

We analyzed BMD in 495 middle-aged women (defined as women > or =40 years of age); 263 women had HIV infection, and 232 women were HIV-negative with behavioral risk factors similar to those of the HIV-positive group.

RESULTS

The median age of the women in the study was 44 years, 54% were black, and 92% had used illicit drugs. Femoral neck BMD and lumbar spine BMD were reduced in women with HIV infection, compared with women without HIV infection (femoral neck BMD, 1.01+/-0.13 g/cm2 vs. 1.05+/-0.13 g/cm2; P=.001; lumbar spine BMD, 1.21+/-0.17 g/cm2 vs. 1.24+/-0.17 g/cm2; P=.04). In addition to HIV infection, other factors independently associated with lower BMD in both sites were being older, not being black, and having a low body weight. In race-stratified multivariate analyses, HIV infection was associated with BMD only in non-black women. Among HIV-positive women, 84% had taken antiretrovirals, and 62% had taken protease inhibitors, but their use was not associated with BMD. Methadone treatment was also independently associated with reduced lumbar spine BMD.

CONCLUSION

Middle-aged women with HIV infection have reduced BMD, compared with women at similar risk for HIV infection, independent of antiretroviral use. Among HIV-positive women, those who are not black, who are underweight, and who use opiates may be at particular risk. Although the prevalence of reduced BMD in this cohort was higher among women with HIV infection than among those without (27% vs. 19%), the overall prevalence of reduced BMD was low, compared with national estimates and with previous studies involving HIV-positive women and men.

Neural circuitry and neuroplasticity in mood disorders: insights for novel therapeutic targets

SUMMARY

Major depressive disorder and bipolar disorder are severe mood disorders that affect the lives and functioning of millions each year. The majority of previous neurobiological research and standard pharmacotherapy regimens have approached these illnesses as purely neurochemical disorders, with particular focus on the monoaminergic neurotransmitter systems. Not altogether surprisingly, these treatments are inadequate for many individuals afflicted with these devastating illnesses. Recent advances in functional brain imaging have identified critical neural circuits involving the amygdala and other limbic structures, prefrontal cortical regions, thalamus, and basal ganglia that modulate emotional behavior and are disturbed in primary and secondary mood disorders. Growing evidence suggests that mechanisms of neural plasticity and cellular resilience, including impairments of neurotrophic signaling cascades as well as altered glutamatergic and glucocorticoid signaling, underlie the dysregulation in these circuits. The increasing ability to monitor and modulate activity in these circuits is beginning to yield greater insight into the neurobiological basis of mood disorders. Modulation of dysregulated activity in these affective circuits via pharmacological agents that enhance neuronal resilience and plasticity, and possibly via emerging nonpharmacologic, circuitry-based modalities (for example, deep brain stimulation, magnetic stimulation, or vagus nerve stimulation) offers promising targets for novel experimental therapeutics in the treatment of mood disorders.

Bone mineral density in premenopausal women with major depression

AIM

To investigate the relationship between the major depression and bone mineral density (BMD) in premenopausal women.

MATERIAL AND METHODS

We compared BMD, plasma cortisol level, osteocalcin and C-telopeptide levels of 35 premenopausal women with major depression with those of 30 healthy women who were matched for age and body mass index. Major depression was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria. Nineteen patients had mild and 16 patients had moderate severity of major depression as measured by Hamilton rating scale for depression.

RESULTS

Women with any risk factor for osteoporosis were excluded from the study. All women underwent BMD measurement by DEXA at lumbar (L2-4) and femoral neck region. After an overnight fasting, plasma cortisol levels were measured at 08:00 h by using competitive immunoassay method. Osteocalcin and C-telopeptide were used for the evaluation of bone turnover. There were no significant differences in BMD, plasma cortisol level, osteocalcin and C-telopeptide levels between the patients and the control groups. There was also no correlation between the plasma cortisol level, the duration and the severity of disease, antidepressant drug use and BMD.

CONCLUSION

Major depression had no significant effect on BMD and bone turnover markers in our patient group of mild to moderate severity of the disorder.

Factors associated with the lumbar spine and proximal femur bone mineral density in older men

Bone mass is a major determinant of fracture, but there have been few comprehensive studies of the correlates of bone mineral density (BMD) in older men. The objective of the current cross-sectional analysis was to determine the factors associated with BMD of the lumbar spine and proximal femur in a large population-based sample of older men enrolled in The Osteoporotic Fractures in Men Study, "Mr.OS." We enrolled 5,995 men 65 years of age or older, 89% Caucasian, in Mr.OS at six US clinical centers. Demographic, medical and family history and lifestyle information was obtained by interview and physical function and anthropometric data by examination. Spine and hip BMD was measured using dual-energy X-ray absorptimetry. The multivariable linear regression models predicted 19 and 10% of the overall variance in BMD of the femoral neck and spine, respectively. African-American men had 6 to 11% higher BMD than Caucasian men independent of multiple factors. Hip BMD declined with advancing age, while spine BMD increased. Body weight (per 10 kg) and self report of diabetes were each associated with 2 to 4% higher BMD, while history of a non-trauma fracture and current use of selective serotonin reuptake inhibitors, but not other antidepressants, were associated with at least 4% lower BMD. Both maternal and paternal histories of fracture were associated with 1.4-1.7% lower BMD. Osteoarthritis, physical activity, grip strength, alcohol intake, and dietary calcium were positively related to BMD, while a history of chronic lung disease, prostate cancer, and kidney stones was associated with lower BMD. Smoking, caffeine intake, and thiazide diuretics were not related to BMD in older men. A number of lifestyle and behavioral characteristics and medical conditions were associated with BMD in older men. Identification of these correlates could improve methods to identify men at risk for fracture and improve our understanding of fracture etiology.

Bone mineral density in subjects using central nervous system-active medications

PURPOSE

Decreased bone mineral density defines osteoporosis according to the World Health Organization and is an important predictor of future fractures. The use of several types of central nervous system-active drugs, including benzodiazepines, anticonvulsants, antidepressants, and opioids, have all been associated with increased risk of fracture. However, it is unclear whether such an increase in risk is related to an effect of bone mineral density or to other factors, such as increased risk of falls. We sought to examine the relationship between bone mineral density and the use of benzodiazepines, anticonvulsants, antidepressants, and opioids in a representative US population-based sample.

SUBJECTS AND METHODS

We analyzed data on adults aged 17 years and older from the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994). Total femoral bone mineral density of 7114 male and 7532 female participants was measured by dual-energy x-ray absorptiometry. Multivariable linear regression models were used to quantify the relation between central nervous system medication exposure and total femoral bone mineral density. Models controlled for relevant covariates, including age, sex, and body mass index.

RESULTS

In linear regression models, significantly reduced bone mineral density was found in subjects taking anticonvulsants (0.92 g/cm2; 95% confidence interval [CI]: 0.89 to 0.94) and opioids (0.92 g/cm2; 95% CI: 0.88 to 0.95) compared with nonusers (0.95 g/cm2; 95% CI: 0.95 to 0.95) after adjusting for several potential confounders. The other central nervous system-active drugs--benzodiazepines or antidepressants--were not associated with significantly reduced bone mineral density.

CONCLUSION

In cross-sectional analysis of NHANES III, anticonvulsants and opioids (but not benzodiazepines or antidepressants) were associated with significantly reduced bone mineral density. These findings have implications for fracture-prevention strategies.

Neural regulation of bone and the skeletal effects of serotonin (5-hydroxytryptamine)

There is increasing evidence for a contribution of the neural system to the regulation of bone metabolism. The skeleton is richly innervated by both sympathetic and sensory neurons. While these nerves serve sensory and vascular functions, they are also being found to influence bone cell activities. The most convincing evidence for this has been provided by studies into the skeletal effects of the hormone leptin, which has been shown to centrally regulate bone mass, and through studies into the skeletal effects of hypothalamic neuropeptide Y2 and Y4 receptors. This paper discusses recent evidence for the neural regulation of bone metabolism and, in particular, the potential role of the neurotransmitter serotonin (5-hydroxytryptamine, 5-HT). Recent studies have demonstrated the presence of functional pathways in bone for both responding to and regulating the uptake of 5-HT. This is of high clinical relevance given the role of the serotonergic system in affective disorders, and the wide use of pharmacological agents that target the 5-HT system to manage these disorders. Initial data suggest that exposure to these agents at different stages during the lifespan may have significant effects on the skeleton.

Depression in anorexia nervosa: a risk factor for osteoporosis

CONTEXT

Both anorexia nervosa (AN) and depression are associated with osteoporosis. We hypothesized that adolescent girls with AN and depression will have lower bone mineral density (BMD) than anorexic girls without depression.

OBJECTIVE

The objective of this study was to investigate whether depression is an independent risk factor for osteoporosis in anorexic adolescent girls.

DESIGN

This study was cross-sectional.

SETTING

This study was conducted at the University Children's Hospital (Bialystok, Poland) from October 2002 through September 2003.

PARTICIPANTS

Forty-five Caucasian anorexic girls aged 13-23 yr, matched by age, Tanner stage, weight, height, calcium intake, and duration of AN, were studied, including 14 with comorbid depression (based on Hamilton Depression Rating Scale and Montgomery-Asberg Depression Rating Scale) and 31 anorexic girls without depression.

MAIN OUTCOME MEASURES

Total body and lumbar spine (LS) BMD, fat mass, and lean mass assessed using dual-energy x-ray absorptiometry were compared between AN girls with and without depression.

RESULTS

BMD was reduced in both groups, relative to reference data, but girls with AN and depression had lower BMD than those with AN alone (LS Z-scores, -2.6 +/- 0.3 vs. -1.7 +/- 0.3; P = 0.02) (mean +/- sem). Quantitative assessment of depression correlated independently with total body BMD (r = -0.4; P < 0.05) and LS BMD (r = -0.6; P < 0.001).

CONCLUSION

Anorexic girls with depression are at higher risk of osteoporosis than those without depression. The mechanisms responsible for decreased BMD in depression are not known. Independent treatment of the depressive disorder in AN may partly alleviate the bone fragility.

A double-blind, placebo-controlled, exploratory trial of chromium picolinate in atypical depression: effect on carbohydrate craving

BACKGROUND

: In a small pilot trial, patients with atypical depression demonstrated significant positive therapeutic response to chromium picolinate. This finding is of interest because of the demonstrated link between depression, decreased insulin sensitivity, and subsequent diabetes and chromium picolinate's insulin enhancing effect.

METHODS

: In this double-blind, multicenter, 8-week replication study, 113 adult outpatients with atypical depression were randomized 2:1 to receive 600 mug/day of elemental chromium, as provided by chromium picolinate (CrPic), or placebo. Primary efficacy measures were the 29-item Hamilton Depression Rating Scale (HAM-D-29) and the Clinical Global Impressions Improvement Scale (CGI-I).

RESULTS

: Of the 113 randomized patients, 110 (70 CrPic, 40 placebo) constituted the intent-to-treat (ITT) population (i.e., received at least one dose of study medication and completed at least one efficacy evaluation) and 75 (50 CrPic, 25 placebo) were evaluable (i.e., took at least 80% of study drug with no significant protocol deviations). In the evaluable population, mean age was 46 years, 69% were female, 81% were Caucasian, and mean body mass index (BMI) was 29.7. There was no significant difference between the CrPic and placebo groups in both the ITT and evaluable populations on the primary efficacy measures, with both groups showing significant improvement from baseline on total HAM-D-29 scores during the course of treatment (p < 0.0001). However, in the evaluable population, the CrPic group showed significant improvements from baseline compared with the placebo group on 4 HAM-D-29 items: appetite increase, increased eating, carbohydrate craving, and diurnal variation of feelings. A supplemental analysis of data from the subset of 41 patients in the ITT population with high carbohydrate craving (26 CrPic, 15 placebo; mean BMI = 31.1) showed that the CrPic patients had significantly greater response on total HAM-D-29 scores than the placebo group (65% vs. 33%; p < 0.05) as well as significantly greater improvements on the following HAM-D-29 items: appetite increase, increased eating, carbohydrate craving, and genital symptoms (e.g., level of libido). Chromium treatment was well-tolerated.

LIMITATIONS

: The study did not include a placebo run-in period, did not require minimum duration or severity of depression, and enrolled patients with major depression, dysthymia, or depression NOS.

CONCLUSIONS

: In a population of adults with atypical depression, most of whom were overweight or obese, CrPic produced improvement on the following HAM-D-29 items: appetite increase, increased eating, carbohydrate craving, and diurnal variation of feelings. In a subpopulation of patients with high carbohydrate craving, overall HAM-D-29 scores improved significantly in patients treated with CrPic compared with placebo. The results of this study suggest that the main effect of chromium was on carbohydrate craving and appetite regulation in depressed patients and that 600 mug of elemental chromium may be beneficial for patients with atypical depression who also have severe carbohydrate craving. Further studies are needed to evaluate chromium in depressed patients specifically selected for symptoms of increased appetite and carbohydrate craving as well as to determine whether a higher dose of chromium would have an effect on mood.

Long-term mental distress, bone mineral density and non-vertebral fractures. The Tromsø Study

The purpose of this study was to examine, prospectively, the risk of non-vertebral fractures and low bone mineral density in a population-based cohort with respect to indicators of subjective mental distress. In 1979-1980 all males born 1925-1959 and all females born 1930-1959 living in Tromsø were invited (21,441; response rate, 78%). The same individuals were invited to the subsequent studies in 1986-1987 and 1994-1995 (74% attended the first two, and 71% attended all three surveys). Non-vertebral fractures were registered by linkage to the hospital X-ray register for the period 1988-1995, and forearm bone mineral density (BMD) was available in a subsample of 4,690 who had attended three times. Questions about mental distress (depression, insomnia and coping problems) were repeated three times and analyzed as cumulated exposure. Women who reported being depressed at two time points had an adjusted odds ratio (OR) =2.5 (95% confidence interval [CI] 1.3-4.9) for sustaining a non-vertebral fracture and OR=3.1 (95% CI 1.3-7.2) for sustaining an osteoporotic fracture, compared with those without depression on any occasion. The corresponding odds ratios for those with coping problems at two time points were slightly higher, whereas sleeping problems seem only to be weakly associated with non-vertebral fractures. The pattern of associations and the magnitude of OR estimates were mainly the same in women younger than 50 years and those 50 years and older. Women using nerve medicine and reporting depression twice had an odds ratio of 4.4 (95% CI 1.1-17.7) for sustaining a non-vertebral fracture, and those using nerve medicine and reporting coping problems twice had a corresponding OR 4.7 (95% CI 1.2-18.4). Among men no significant associations were found for either fracture type. No association was found between mean BMD and number of times reporting depression, insomnia or coping problems, in women or men. Long-term mental distress is associated with risk of all non-vertebral fractures and osteoporotic fractures in middle-aged women, but not in men. Mental distress itself seems to be more important than the use of nerve medicine.

Depression in the elderly

In elderly people, depression mainly affects those with chronic medical illnesses and cognitive impairment, causes suffering, family disruption, and disability, worsens the outcomes of many medical illnesses, and increases mortality. Ageing-related and disease-related processes, including arteriosclerosis and inflammatory, endocrine, and immune changes compromise the integrity of frontostriatal pathways, the amygdala, and the hippocampus, and increase vulnerability to depression. Heredity factors might also play a part. Psychosocial adversity-economic impoverishment, disability, isolation, relocation, caregiving, and bereavement-contributes to physiological changes, further increasing susceptibility to depression or triggering depression in already vulnerable elderly individuals. Treatment with antidepressants is well tolerated by elderly people and is, overall, as effective as in young adults. Evidence-based guidelines for prevention of new episodes of depression are available as are care-delivery systems that increase the likelihood of diagnosis, and improve the treatment of, late-life depression. However, in North America at least, public insurance covers these services inadequately.

Depression and bone mineral density: is there a relationship in elderly Asian men? Results from Mr. Os (Hong Kong)

Previous epidemiological study has suggested that depression might be associated with low bone mass in Caucasian women. This has not been studied in Asian men. Mr. Os (Hong Kong) is the first, large, cohort study on osteoporosis in Asian men, and the current analysis deals with the association between depression and bone mass in this group. Data from the baseline examination of Mr. Os (Hong Kong) were used. Two thousand Hong Kong men aged 65 to 92 years were recruited from the community. Depression was diagnosed by face-to-face interview, using a validated Chinese version of the Geriatric Depression Scale (GDS), with depression being defined as a cut-off score of 8 or more. Bone mineral density (BMD) of the lumbar spine, total hip and total body was measured by dual X-ray densitometry (DEXA) using the Hologic QDR-4500 W densitometer. Multiple regression was used to compare BMD in depressed and non-depressed subjects, controlling for confounding variables. In the study sample 8.5% of men were found to be depressed, and the BMD at the total hip in these subjects was 2.1% lower than in non-depressed subjects (95% CI -0.13 to -4.1), after adjustment for age, body weight, medical history, alcohol consumption, cigarette smoking, calcium intake, physical activity and antidepressant use. Depression was associated with a 1.4-fold (95% CI 1.00 to 2.08) relative risk (RR) of being diagnosed with a T-score equal to or less than -1.0 (low bone mass). We conclude that depression is associated with lower BMD; however, to determine whether depression causes lower BMD or vice versa, we will need to await findings from future prospective studies.

Type D personality: the heart, stress, and cortisol

Many studies have demonstrated the role of psychosocial and behavioural risk factors in the aetiology and pathogenesis of cardiovascular disorders. Recently, a new personality construct, the type D or 'distressed' personality, has been proposed. Type D behaviour is characterized by the joint tendency to experience negative emotions and to inhibit these emotions while avoiding social contacts with others. The observation that cardiac patients with type D personality are at increased risk for cardiovascular morbidity and mortality underlines the importance of examining both acute (e.g. major depression) and chronic (e.g. certain personality features) factors in patients at risk for coronary events. Both type D dimensions (negative affectivity and social inhibition) are associated with greater cortisol reactivity to stress. Elevated cortisol may be a mediating factor in the association between type D personality and the increased risk for coronary heart disease and, possibly, other medical disorders. Studies of the effect of age on hypothalamic-pituitary-adrenal (HPA) function in healthy humans have produced inconsistent results. This may relate to a different prevalence of type D individuals in study samples (i.e. some type D individuals may have alterations within the HPA axis that are similar to HPA axis changes in depressed patients). Further studies of the psychological and biological features of type D individuals may help develop treatment approaches to improve the psychological and physical health of individuals with type D personality.

The role of stress-induced cortisol in the relationship between depression and decreased bone mineral density

BACKGROUND

This study was designed to test the hypothesis that cortisol mediates the relationship between bone density and depression in postmenopausal women.

METHODS

Nineteen women aged 52-79 who had been assessed for bone mineral density by dual-energy x-ray absorptiometer (DEXA) were evaluated for depression and anxiety. Diurnal and stress-induced measures of salivary cortisol were obtained during the following week and at a laboratory session involving a speech task.

RESULTS

Nine volunteers reported depression while 10 were never depressed. Ever depressed women had significantly lower total lumbar and right femur DEXA Z scores than never depressed (t(17) = 2.5, p = .019 and t(17) = 2.06, p = .05, respectively). Ever depressed women demonstrated a significant increase in salivary cortisol (area under the curve (AUC) = 27.83, SD = 37.64) compared to never depressed women (AUC = -13.34, SD = 19.55) (t(17) = -3.041, p = .007) during a psychological challenge. There were significant inverse relationships between salivary cortisol AUC values and bone density Z scores at every measured bone site. Mediation analyses suggest that 51 - 67% of the association between depression and bone density could be attributed to stress-induced changes in cortisol.

CONCLUSIONS

Cortisol hypersecretion in response to stress may, in part, explain the impact of depression on bone density in post-menopausal women.

Decreased osteoprotegerin and increased bone turnover in young female patients with major depressive disorder and a lifetime history of anorexia nervosa

Low bone mineral density (BMD) is a frequent, often persistent complication in patients with major depressive disorder (MDD) and anorexia nervosa (AN) that increases the risk of pathologic fractures. The pathogenetic process underlying osteopenia in MDD and AN is still unclear, although several factors, including a dysbalance of cytokines, are associated with loss of bone mass. Alterations in the serum levels of cytokines have been observed in patients with MDD, AN, and other psychiatric disorders. Therefore, we examined serum levels of cytokines, markers of bone turnover, and BMD in 13 patients with MDD and a lifetime history of AN. Bone turnover markers (osteocalcin and C-terminal degradation products of type I collagen) and tumor necrosis factor alpha (TNF-alpha) in patients were significantly increased compared with those of the control group. Osteoprotegerin (OPG) in patients was significantly decreased. Eight of 13 patients (62%) displayed osteopenia at the lumbar spine. TNF-alpha correlated significantly with C-terminal degradation products of type I collagen, an osteoclastic marker, but significantly negatively with OPG. Our data suggest that TNF-alpha and OPG may play a role in the pathogenetic process underlying osteopenia in these patients.

Depression symptoms and antidepressant medicine use in Diabetes Prevention Program participants

OBJECTIVE

To assess depression markers (symptoms and antidepressant medicine use) in Diabetes Prevention Program (DPP) participants and to determine whether changes in depression markers during the course of the study were associated with treatment arm, weight change, physical activity level, or participant demographic characteristics.

RESEARCH DESIGN AND METHODS

DPP participants (n = 3,187) in three treatment arms (intensive lifestyle, metformin, and placebo) completed the Beck Depression Inventory (BDI) and reported on use of antidepressant medicines at randomization and subsequently at each annual visit (average duration in study 3.2 years).

RESULTS

On study entry, 10.3% of participants had BDI scores > or =11, which was used as a threshold for mild depression, 5.7% took antidepressant medicines, and 0.9% had both depression markers. During the DPP, the proportion of participants with elevated BDI scores declined (from 10.3% at baseline to 8.4% at year 3), while the proportion taking antidepressant medicines increased (from 5.7% at baseline to 8.7% at year 3), leaving the proportion with either marker unchanged. These time trends were not significantly associated with the DPP treatment arm. Depression markers throughout the study were associated with some participant demographic factors, adjusted for other factors. Men were less likely to have elevated depression scores and less likely to use antidepressant medicine at baseline (9.0% of men and 17.9% of women had at least one marker of depression) and throughout the study (P <0.0001). Those with more education were less likely to have elevated symptom scores (P = 0.0007) but more likely to be taking antidepressant medicine (P = 0.002). Non-Hispanic white participants were less likely than African Americans to have BDI scores > or =11 (P = 0.03), but white participants were more likely to be taking antidepressant medicine than any other racial/ethnic group (P <0.0001).

CONCLUSIONS

DPP participation was not associated with changes in levels of depression. Countervailing trends in the proportion of DPP participants with elevated depression symptoms and the proportion taking antidepressant medicine resulted in no significant change in the proportion with either marker. The finding that those taking antidepressant medicine often do not have elevated depression symptoms indicates the value of assessing both markers when estimating overall depression rates.

Depression and hip fracture risk: the NHANES I epidemiologic follow-up study

OBJECTIVE

Since hip fracture is the most devastating consequence of osteoporosis from a public health standpoint, addressing whether depression is predictive of fracture risk is important. The purpose of this study is to determine whether individuals with high depressive symptomatology are more likely to suffer an osteoporotic hip fracture than subjects with intermediate or low depressive symptomatology.

METHODS

Data from the first National Health and Nutrition Examination Survey (NHANES I) were obtained from a nationally representative sample of noninstitutionalized civilians. A cohort aged 25 through 74 at baseline (1971-1975) was observed through 1992. Subjects were followed-up for a maximum of 22 years. Included in the analyses were 6,195 white and black subjects. Ninety-five percent of the original cohort completed the study. Hospital records and death certificates were used to identify a total of 122 hip fracture cases.

RESULTS

In an unadjusted Cox proportional hazards regression model for all individuals, depression was predictive of hip fracture (hazard ratio [HR]=1.90; 95% confidence interval [CI]=1.13, 3.21; p=0.016). In a multivariate proportional hazards model controlling for (1) age at baseline, (2) gender, (3) race, (4) body mass index, (5) smoking status, (6) alcohol consumption, and (7) physical activity level, high depressive symptomatology remained predictive of hip fracture (HR=1.70; 95% CI=0.99, 2.91; p=0.055).

CONCLUSIONS

This study gives evidence of a prospective association between depression and hip fracture. Additional studies are needed to verify these findings and to elucidate the pathways for the effects of depression on hip fracture incidence.

ENDOCRINOLOGY OF THE STRESS RESPONSE

The stress response is subserved by the stress system, which is located both in the central nervous system and the periphery. The principal effectors of the stress system include corticotropin-releasing hormone (CRH); arginine vasopressin; the proopiomelanocortin-derived peptides alpha-melanocyte-stimulating hormone and beta-endorphin, the glucocorticoids; and the catecholamines norepinephrine and epinephrine. Appropriate responsiveness of the stress system to stressors is a crucial prerequisite for a sense of well-being, adequate performance of tasks, and positive social interactions. By contrast, inappropriate responsiveness of the stress system may impair growth and development and may account for a number of endocrine, metabolic, autoimmune, and psychiatric disorders. The development and severity of these conditions primarily depend on the genetic vulnerability of the individual, the exposure to adverse environmental factors, and the timing of the stressful events, given that prenatal life, infancy, childhood, and adolescence are critical periods characterized by increased vulnerability to stressors.

Polyunsaturated fatty acids: biochemical, nutritional and epigenetic properties

Dietary polyunsaturated fatty acids (PUFA) have effects on diverse physiological processes impacting normal health and chronic diseases, such as the regulation of plasma lipid levels, cardiovascular and immune function, insulin action and neuronal development and visual function. Ingestion of PUFA will lead to their distribution to virtually every cell in the body with effects on membrane composition and function, eicosanoid synthesis, cellular signaling and regulation of gene expression. Cell specific lipid metabolism, as well as the expression of fatty acid-regulated transcription factors, likely play an important role in determining how cells respond to changes in PUFA composition. This review will focus on recent advances on the essentiality of these molecules and on their interplay in cell physiology, leading to new perspective in different therapeutic fields.

Thyroid and adrenal axis in major depression: a controlled study in outpatients

OBJECTIVE

Major depressive disorder has been associated with changes in the hypothalamus-pituitary-thyroid (HPT) axis and with hypercortisolism. However, the changes reported have been at variance, probably related to in- or outpatient status, the use of antidepressant medication and the heterogeneity of depression. We therefore conducted a controlled study in unipolar depressed outpatients who had been free of antidepressants for at least 3 months.

DESIGN

We assessed endocrine parameters in 113 depressed outpatients and in 113 sex- and age-matched controls.

METHODS

Patients were included if they had a major depression according to a Structural Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM), fourth edition (SCID-IV) and if they had a 17-item Hamilton rating scale for depression (HRSD) score of > or =16. Endocrine parameters contained serum concentrations of TSH, (free) thyroxine, tri-iodothyronine, cortisol, thyroid peroxidase (TPO) antibody titre and 24-h urinary excretion of cortisol.

RESULTS

The serum concentration of TSH was slightly higher in depressed patients as compared with controls (P < 0.001), independent of the presence of subclinical hypothyroidism and/or TPO antibodies (n = 28). All other HPT axis parameters were similar in both groups. The 24-h urinary cortisol excretion was similar in patients and controls. In atypical depression, serum cortisol was lower than in non-atypical depression (P = 0.01). Patients with neither melancholic depression nor severe depression (HRSD > or =23) had altered endocrine parameters. Finally, serum TSH values could not be related to cortisol values.

CONCLUSION

When compared with matched control subjects, outpatients with major depression had slightly higher serum TSH, while urinary cortisol levels were similar. Furthermore, we observed lower serum cortisol in atypical depression than in non-atypical depression.

Inhibition of the serotonin (5-hydroxytryptamine) transporter reduces bone accrual during growth

Selective serotonin-reuptake inhibitors (SSRIs) antagonize the serotonin (5-hydroxytryptamine) transporter (5-HTT), and are frequently prescribed to children and adolescents to treat depression. However, recent findings of functional serotonergic pathways in bone cells and preliminary clinical evidence demonstrating detrimental effects of SSRIs on bone growth have raised questions regarding the effects of these drugs on the growing skeleton. The current work investigated the impact of 5-HTT inhibition on the skeleton in: 1) mice with a null mutation in the gene encoding for the 5-HTT; and 2) growing mice treated with a SSRI. In both models, 5-HTT inhibition had significant detrimental effects on bone mineral accrual. 5-HTT null mutant mice had a consistent skeletal phenotype of reduced mass, altered architecture, and inferior mechanical properties, whereas bone mineral accrual was impaired in growing mice treated with a SSRI. These phenotypes resulted from a reduction in bone formation without an increase in bone resorption and were not influenced by effects on skeletal mechanosensitivity or serum biochemistries. These findings indicate a role for the 5-HTT in the regulation of bone accrual in the growing skeleton and point to a need for further research into the prescription of SSRIs to children and adolescents.

Quality-of-life issues in osteoporosis

Osteoporosis is responsible for more than 1.5 million fractures per year in the United States including vertebral and nonvertebral fractures of the hip and wrist. Most of the impact of osteoporosis on quality of life relates to fracture. While the morbidity and mortality of hip fractures have long been recognized, only recently have we also recognized the significant burden of vertebral fractures. With the development of generic and disease targeted quality-of-life instruments we have now confirmed observational studies showing that clinical vertebral fractures have significant effects on quality of life. The economic burden of vertebral fractures, if we include direct and indirect costs, may be similar to hip fractures. The relative risk for mortality after clinical vertebral fracture is at least equivalent to that of hip fracture. The burden of vertebral fractures relates not only to pain but also to kyphosis. Because vertebral fractures are often under diagnosed and under treated, these findings are a call to action because the first vertebral fracture leads to significantly increased risk for subsequent vertebral and osteoporotic fracture with further loss of quality of life.

Social stress-associated depression in adult female cynomolgus monkeys (Macaca fascicularis)

This paper describes a behavior pattern in adult female cynomolgus monkeys that has several behavioral and physiological characteristics in common with human depression including reduced body fat, low levels of activity, high heart rate, hypothalamic-pituitary-adrenal (HPA) axis disturbances, and increased mortality. Under certain circumstances, this depressive behavior appears more common in socially stressed subordinate, than dominant, females. This is the first animal model of social stress-related depression in females and the first primate model of adult depression. It is important to have a female animal model of depression because women are more likely to experience a clinically significant depression than men, and depression in women is often associated with changes in reproductive system function. This model is particularly useful because these monkeys have menstrual cycles that are similar to those of women, and those that exhibit depressive behavior have relatively low levels of ovarian steroids. These monkeys may be a useful model of reproductive system-associated mood disorders in females.

Depression and bone mineral density in a community sample of perimenopausal women: Geelong Osteoporosis Study

OBJECTIVE

Reduced bone mineral density (BMD) in women with a history of depressive disorders has been shown in some, but not all studies. This study investigated the association between self-reported depression and BMD in an age-stratified community sample of perimenopausal women residing in the South-Eastern region of Australia.

DESIGN

Symptoms of depression in the year between July 2000 and July 2001 were ascertained by a self-report questionnaire based on Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. Women in the perimenopausal group who had undergone a BMD total hip and spine assessment within the 12-month period after the depression assessment were included in the analysis, resulting in a sample of 78 women aged 45 to 60 years.

RESULTS

In this sample, 14 women were identified as depressed. There was no difference in age, hormone therapy (HT) use, or unadjusted BMD at the total hip or spine between the depressed and nondepressed women (P = 0.14, 0.89, 0.57, and 0.70, respectively), but the depressed women tended to be heavier [depressed (median weight, interquartile range = 80 kg, 66-94) vs nondepressed (72 kg, 61-80) P = 0.06]. Whereas there was no significant difference in age-, HT-, and weight-adjusted BMD at the spine [depressed (mean +/- SE = 1.21 +/- 0.05) vs nondepressed (1.28 +/- 0.03 g/cm(2)) P = 0.18], adjusted BMD at the total hip for the depressed women was 7.8% lower than for the nondepressed [depressed (mean +/- SE = 0.957 +/- 0.038) vs nondepressed (1.038 +/- 0.023 g/cm(2)) P = 0.04].

CONCLUSIONS

These results suggest that in perimenopausal women, self-reported depression is associated with lower BMD at the hip.

Increased mortality in depressive disorders: a review

Several factors have been proposed to explain the relationship between excess mortality and depressive disorders. These include mechanisms such as increased suicide rates, hazardous health behavior (smoking, alcohol use, unhealthy eating), psychologic reactions to developing a medical illness, biological dysregulations (hyperactivity of the hypothalamic pituitary adrenal, neuro-immune dysregulation, sympathoadrenergic dysregulation), and noncompliance with medical treatment. The evidence supporting the role of each of these mechanisms in excess mortality varies considerably. The causal direction in most of the mechanisms is not clear. It is possible that the explanatory factors, such as smoking, compliance, or biological mechanisms, cause depression, or that depression causes these factors, or that both are explained by a third, underlying factor. We will summarize the evidence supporting these mechanisms, and propose options for possible interventions aimed at reducing the increased risk of dying.

Bone mineral density during maintenance treatment with supraphysiological doses of levothyroxine in affective disorders: a longitudinal study

BACKGROUND

This prospective study was designed to determine whether patients with prophylaxis-resistant affective disorders, receiving adjunctive maintenance therapy with supraphysiological doses of levothyroxine (L-T4), show evidence of accelerated bone loss compared to the reference population database.

METHODS

In 21 patients, bone mineral density (BMD) of the spine (lumbar vertebrae L1-L4) and femur (femoral neck, trochanter, and Ward's triangle) was measured by dual energy X-ray absorptiometry (DXA). BMD measurement was performed first after patients had been on thyroid-stimulating hormone (TSH)-suppressive therapy with L-T4 (mean dose=411 mcg/d) for an average of 16.4 months and again after 33.6 months of L-T4 (mean dose=416 mcg/d) therapy.

RESULTS

There was no statistically significant difference between the actual percentage decline in bone mineral density and the expected percentage decline in any of the measured bone regions. In a stepwise linear regression analysis, age was identified as a predictor of percentage change in BMD. After controlling for age, the only other variable that showed a consistent trend was the dose of L-T4, with higher doses being positively correlated with the percentage decline of BMD.

LIMITATIONS

Relatively small sample size, no bone density assessment prior to treatment with L-T4, no patient control group with mood disorders who did not receive L-T4 treatment, and bone density follow-up intervals were variable.

CONCLUSIONS

This study did not demonstrate evidence that long-term treatment of affectively ill patients with supraphysiological doses of L-T4 significantly accelerates loss of bone mineral density compared to the age-matched reference population. However, the decline of BMD in one individual patient underscores that caution is indicated and that regular assessment of BMD during longer-term supraphysiological thyroid hormone treatment is needed.

Depression and concomitant diseases in a Turkish geriatric outpatient setting

Depression is an important but inadequately diagnosed mood disorder in elderly. Depressed elderly patients often have chronic concomitant diseases. This paper intended to determine the prevalence of depression and its relation with concomitant disorders and social status among the patients admitted to our geriatric unit. Seven hundred and eighty-nine females and 466 males admitted to our unit were examined for the presence of depression by using the geriatric depression scale (GDS) test. The presence of concomitant diseases was assessed. Depression was diagnosed in 273 patients (21.8%), 193 (70.7%) females and 80 (29.3%) males. Depressed patients suffered from a wide range of other diseases the number and prevalence of which were as follows: Alzheimer's disease (AD) (34; 12.5%), vascular dementia (27; 9.9%), hypertension (HT) (211; 77.3%), diabetes mellitus (DM) (64; 23.4%), osteoporosis (182; 66.7%), atherosclerotic coronary artery disease (CAD) (89; 32.6%), cardiac failure (23; 8.5%), bronchial asthma (8; 2.9%), chronic obstructive pulmonary disease (COPD) (25; 9.2%) and osteoarthritis (133; 48.8%). The correlation between depression and concomitant diseases was statistically significant in hypertensive, demented and osteoporotic patients, as determined in a large elderly population. Previous studies examined the correlation of depression with only one concomitant disease, while we performed the analysis on multiple correlations.

Bone mineral density changes in young women: a two year study

Achievement of a high peak bone mass is considered a pivotal preventive strategy against future osteoporotic fractures. The ostensible interaction between physiology and lifestylefor the development of bone mass over time is sparsely outlined among young women. The aim of this study was to follow bone density and bone resorption over time among healthy young women in relation to lifestyle factors and to evaluate the perceived influence of other factors. Data were collected in 1999 and in 2001. Healthy young women (n=152) were given a structured questionnaire, a heel bone scanner (dual X-ray absorptiometry) performed bone mineral density measurements and deoxypyridinoline was measured in urine. Data were analyzed by linear, multiple and logistic regression analysis. Mean bone mineral density (BMD) was 0.562 g/cm2 (+/-0.090). Bone density at baseline was the best predictorfor the bone density atfollow-up. Bone density at baseline together with smoking and alcohol (dichotomized) accounted for 86.5% of the variation in bone density 2 years later. Of the participants 62% had decreased/unchanged bone density and 38% had increased their bone density from 1999 to 2001. Use of oral contraceptives or alcohol at baseline was associated with an increased risk of belonging to the group who decreased their bone density. Deoxypyridinoline was not a strongpredictor to bone density and all potential predictors of deoxypyridinoline had a minor influence (<10%). In conclusion, lifestyle behaviors such as use of oral contraceptives, smoking and alcohol consumption seem to have a negative influence on BMD development among young women and warrant further scrutiny.

Daily hassles, cortisol, and the pathogenesis of depression

Daily hassles and/or ongoing stress are associated with increased cortisol secretion in healthy individuals. Hassles are also associated with increased cortisol levels in depressed patients. Considerable evidence suggests that hypercortisolism is involved in the pathogenesis of depressive disorders. Over the past decade, there has been a shift from viewing excessive hypothalamic-pituitary-adrenal (HPA) activity in depression as an epiphenomenon to its having specific effects on symptom formation. The author suggests that increased cortisol secretion caused by daily hassles and/or ongoing stress contributes to the development of depressive disorders. Minor stressful events may lead to depression in vulnerable individuals. Genetic factors interact with environmental factors to influence the vulnerability to stress and mood disorders. The author also proposes that elevated cortisol levels associated with stressful daily events may worsen the condition of depressed patients. The author notes that one of the goals of prevention of stress-related disorders is to help individuals be more competent in managing their behavior and emotions in reaction to negative aspects of their environment, and briefly discusses stress management methods and techniques. The risk of developing depression is determined by a complex interplay between genetic susceptibility, environmental exposures, and aging. These influences also account for long term changes in the regulation of HPA function. Further studies of HPA function may not only advance our understanding of the role of the HPA system in the etiology and pathogenesis of psychiatric disorders, but also be useful in refining conceptions of psychiatric disorders themselves and possible approaches to the treatment of these conditions.

Serotonin regulates osteoclast differentiation through its transporter

5-HTT mediates antidepressant-sensitive clearance of 5-HT after its release into neural synapses. We found increased expression of 5-HTT in RANKL-induced osteoclast-like cells. Fluoxetine, an inhibitor of 5-HTT, reduced osteoclast differentiation but not activation. Reserpine, an inhibitor of 5-HT intracellular transport, potentiated differentiation. These results indicate a role for 5-HTT in osteoclast function and suggest that commonly used antidepressive agents may affect bone mass.

INTRODUCTION

Interactions between the serotonergic and skeletal systems are suggested by various clinical observations but are poorly understood.

MATERIALS AND METHODS

Using gene microarrays, we found that the serotonin transporter (5-HTT) was strongly expressed in RANKL-induced osteoclasts. Using RANKL stimulation of RAW264.7 cells and mouse bone marrow cells as a model system for osteoclast differentiation, we studied the possible role/s of the different components of the serotonin (5-HT) system on the differentiation process.

RESULTS

Osteoclast 5-HTT exhibited typical 5-HT uptake activity that was inhibitable by fluoxetine (Prozac). Fluoxetine reduced osteoclast differentiation but did not inhibit the activation of preformed osteoclasts, whereas the addition of 5-HT itself enhanced differentiation. Fluoxetine-treated osteoclast precursors had reduced NF-kappa B activation and elevated inhibitory protein kappa B alpha (I kappa B alpha) levels compared with untreated cells. 5-HT, on the other hand, resulted in activation of NF-kappa B. Reserpine inhibition of intracellular transport of 5-HT into cytoplasmic vesicles potentiated RANKL-induced osteoclast formation, suggesting the importance of intracellular 5-HT in regulating osteoclast differentiation. Reserpine also modestly enhanced the expression of the osteoclast marker TRACP in the absence of RANKL.

CONCLUSIONS

Taken together, these data suggest that the 5-HT system plays an important role in bone homeostasis through effects on osteoclast differentiation and implies that commonly used antidepressive agents may affect bone mass.

[The hypothalamic pituitary adrenal axis, glucocorticoid receptor function and relevance to depression]

OBJECTIVES

Changes in the hypothalamic-pituitary-adrenocortical (HPA) system are characteristic of depression. Because the effects of glucocorticoids are mediated by intracellular receptors including, most notably, the glucocorticoid receptor (GR), several studies have examined the number and/or function of GRs in depressed patients.

METHODS

Review scientific evidences have consistently demonstrated that GR function is impaired in major depression, resulting in reduced GR-mediated negative feedback on the HPA axis and increased production and secretion of CRF in various brain regions postulated to be involved in the causality of depression.

RESULTS

This article summarizes the literature on GR in depression and on the impact of antidepressants on the GR in clinical and preclinical studies, and supports the concept that impaired GR signalling is a key mechanism in the pathogenesis of depression, in the absence of clear evidence of decreased GR expression. The data also indicate that antidepressants have direct effects on the GR, leading to enhanced GR function and increased GR expression. Although the effects of antidepressants on glucocorticoid hormones and their receptors are relevant for the therapeutic action of these drugs, the molecular mechanisms underlying these effects are unclear. We propose that antidepressants in humans could inhibit steroid transporters localised on the blood-brain barrier and in neurones, like the multidrug resistance p-glycoprotein, and thus increase the access of cortisol to the brain and the glucocorticoid-mediated negative feedback on the HPA axis.

CONCLUSION

Enhanced cortisol action in the brain might prove to be a successful approach to maximise therapeutic antidepressant effects. Hypotheses regarding the mechanism of these receptor changes involve non-steroid compounds that regulate GR function via second messenger pathways. Research in this field will lead to new insights into the pathophysiology and treatment of affective disorders.

Where psychology meets physiology: chronic stress and premature mortality--the Central-Eastern European health paradox

A substantial and still growing body of research tries to link different psychological models and chronic diseases, with special emphasis on cardiovascular disease. These efforts have established several conceptual bridges that connect psychological alterations and psychosocial factors to the risks, onset and prognosis of cardiovascular disease. However, several different models have been suggested. Depression and learned helplessness are two central psychological models that have been shown to have major explanatory power in the development of chronic diseases. In this respect the so called Central-Eastern European health paradox, that is the morbidity and mortality crisis in these transforming societies can be regarded as a special experimental model. In this review chronic stress is proposed as an integrating theory that can be applied to different psychological models. Chronic stress and allostatic load has been shown to lead to typical pathogenetic results in animal experiments. Chronic stress theory is applicable to the explanation of the suddenly changing patterns of premature mortality rates in transforming societies. Literature and the different models in the field of psychology, behavioural sciences, and epidemiology are reviewed in terms of the chronic stress theory. The applicability of these results are investigated for further research, clinical and policy implications.

Depression and bone mineral density in young adults: results from NHANES III

OBJECTIVE

The purpose of this cross-sectional population-based study was to assess the association of major depressive episode (MDE) and dysthymia with bone mineral density (BMD) in young adults.

METHODS

Data are from a nationally representative sample of 5,171 people aged 20 to 39 years from the Third National Health and Nutrition Examination Survey. Total proximal femoral BMD was measured using dual energy x-ray absorptiometry. MDE and dysthymia were measured using the Diagnostic Interview Schedule.

RESULTS

MDE was associated with lower BMD in multivariate models in men (mean BMD = 1.038 vs. 1.068 g/cm(2); odds ratio (OR) per 1 SD decline in BMD = 1.65, 95% confidence interval (CI) = 1.08-2.52; p = 0.02) but not in women (mean BMD = 0.982 vs. 0.979 g/cm(2); OR = 0.96, 95% CI = 0.71-1.30; p =.79). The same divergence by gender was seen for dysthymia.

CONCLUSION

The relationship between BMD and MDE or dysthymia in young adults varies by gender.

Depressive symptoms and bone mineral density in older men

Most studies examining the relation between depression and bone mineral density (BMD) have been limited to psychiatric patients or to community-dwelling, older women. We conducted a cross-sectional and prospective cohort study to determine whether depressive symptoms are associated with low BMD in community-dwelling, older men. We recruited 515 men 50 years of age or older from population-based listings of age-eligible men. Participants completed the Geriatric Depression Scale (short form) and were considered depressed if they scored 6 or more out of 15 possible points. BMD was measured in the spine and hip using dual energy x-ray absorptiometry in all participants, and again an average of 3.6 years later in a random subset of 100 participants. The prevalence of depressive symptoms (GDS = 6) was 3.1% (16 of 515). We found no difference in mean BMD or mean percent change in BMD per year of the hip and lumbar spine in men who had 6 or more depressive symptoms compared with men who reported 5 or fewer symptoms of depression. These findings suggest that depressive symptoms are not associated with BMD in community-dwelling, older men.