Anxiety and osteoporosis are common diseases and major public health problems. The association between  anxiety levels and bone loss was poorly investigated, thus we aimed to explore whether anxiety severity could be considered as an independent fracture risk. In a setting of postmenopausal women we measured anxiety levels by Hamilton Anxiety Rating Scale (HAMA), depressive symptoms by Beck Depression Inventory and evaluated quality of life by the 36-Item Short Form Health Survey (SF-36) questionnaire. Women with higher anxiety levels showed lower BMD at lumbar spine and femoral neck, and exhibited a poorer quality of life after grouping our population in tertiles of HAMA score. Anxiety levels were predictive of reduced BMD after correcting for other known clinical risk of fractures

Annamaria Pugliese

Antonino Catalano

Carmen Lasco

Federica Bellone

Gabriella Martino

Nunziata Morabito

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APMB - Atti della Accademia Peloritana dei Pericolanti Classe di Scienze Medico Biologiche Vol. 105(2) 2017  ISSN 1828-6550   DOI: 10.6092 / 1828-6550 / APMB.105.2.2017.OS1  APMB - Atti della Accademia Peloritana dei Pericolanti - Classe di Scienze Medico-Biologiche (2017), 105(2):OS1(1-5)  DOI: 10.6092 / 1828-6550 / APMB.105.2.2017.OS1     Original Study OS1(1-5)  Psychological factors may impacton postmenopausal women fracture risk.  Federica Bellone1, Antonino Catalano1, Gabriella Martino2, Carmen Lasco2, Annamaria Pugliese1, Nunziata Morabito1  1 Department of Clinical and Experimental Medicine, University Hospital of Messina, Messina, Italy 2Department of Cognitive Sciences, Psychology, Education and Cultural Studies, University of Messina, Messina, Italy   Abstract Anxiety and osteoporosis are common diseases and major public health problems. The association between  anxiety levels and bone loss was poorly investigated, thus we aimed to explore whether anxiety severity could be considered as an independent fracture risk. In a setting of postmenopausal women we measured anxiety levels by Hamilton Anxiety Rating Scale (HAMA), depressive symptoms by Beck Depression Inventory and evaluated quality of life by the 36-Item Short Form Health Survey (SF-36) questionnaire. Women with higher anxiety levels showed lower BMD at lumbar spine and femoral neck, and exhibited a poorer quality of life after grouping our population in tertiles of HAMA score. Anxiety levels were predictive of reduced BMD after correcting for other known clinical risk of fractures.  KEYWORDS: postmenopausal; osteoporosis; anxiety; depression; quality of life.    IntroducingMember: Gabriella Martino  Corresponding Author: Federica Bellone, federicabellone@hotmail.it  Introduction Postmenopausal osteoporosis is the most common metabolic bone disease affecting aging women and a major public health problem due to its main consequences represented by fractures [1,2]. It is estimated that one in three women and one in five men worldwide will sustain an osteoporotic related bone fracture over the life course. Women with osteoporosis were shown to experiment a weakened quality of life and an increased incidence of anxiety and depressive symptoms. It was also observed that major depression may worsen bone health, but little is known as for the impact of anxiety levels on fracture risk [3]. Anxiety is one of the most common mental disorders with a current global prevalence of 7.3 % [4]. Because anxiety and osteoporosis are highly prevalent in postmenopausal women and because anxiety was previously shown to be associated with an increased risk of developing osteoporosis, we aimed to investigate whether anxiety levels were predictive of bone mineral density and fracture risk in a setting of postmenopausal women.  APMB - Atti della Accademia Peloritana dei Pericolanti Classe di Scienze Medico Biologiche Vol. 105(2) 2017  ISSN 1828-6550   DOI: 10.6092 / 1828-6550 / APMB.105.2.2017.OS1  APMB - Atti della Accademia Peloritana dei Pericolanti - Classe di Scienze Medico-Biologiche (2017), 105(2):OS1(1-5)  DOI: 10.6092 / 1828-6550 / APMB.105.2.2017.OS1 Material and Methods Postmenopausal women (n=192) referred for the assessment of bone health were consecutively enrolled and signed a written informed consent. Patients with a known neurologic or psychiatric condition, kidney or liver or hearth or respiratory failure, cancer, endocrine disorders, or if taking psychotropic drugs or active bone agents were not considered for this research. Based on clinical risk factors (CRFs), fracture risk was evaluated by FRAX® tool [5]. BMD was assessed by the gold-standard dual-energy X-ray absorptiometry (DXA) densitometer (Hologic Discovery) at the lumbar spine (L1-L4) and at femoral site. The Hamilton Anxiety Rating Scale (HAMA) was used to measure the severity of perceived anxiety symptoms [6], the Beck Depression Inventory-second edition (BDI-II) to evaluate levels of depression [7], the Short Form-36 (SF-36) questionnaire to measure the perception of patient health by exploring physical functioning, social functioning, role limitations due to physical problems, role limitations because of emotional problems, mental health, vitality, pain, and general health perception [8]. Student’s t-test for unpaired observations or Mann-Whitney test were used. The degree of association between two variables was obtained by Pearson correlation coefficient, and the relationship between a dependent variable and one or more explanatory variables was calculated by multiple regression analysis. Values of p<0.05 indicated statistical significance.  Results The 192 recruited postmenopausal women were considered all together and after grouping in tertiles of HAMA score. Their main anthropometric, clinical and instrumental features are shown in table 1.  Women in the lower tertile of HAMA score (HAMA-1) exhibited lower ten years probability of major osteoporotic fractures, and women in HAMA-3 showed significantly lower T-score values at both lumbar spine and femoral sites in comparison with women in HAMA-1 (Figure 1).                     Fig 1 - T-score (SD) values according to tertiles of HAMA scores.  APMB - Atti della Accademia Peloritana dei Pericolanti Classe di Scienze Medico Biologiche Vol. 105(2) 2017  ISSN 1828-6550   DOI: 10.6092 / 1828-6550 / APMB.105.2.2017.OS1  APMB - Atti della Accademia Peloritana dei Pericolanti - Classe di Scienze Medico-Biologiche (2017), 105(2):OS1(1-5)  DOI: 10.6092 / 1828-6550 / APMB.105.2.2017.OS1   Data on SF-36 survey are reported in Figure 2. HAMA score was also positively related with BDI-II score (p=0.609, p=<0.001), age (r=0.242, p=0.003), menopausal age (r=0.246, p=0.003), years since menopause (r=-0.182, p=0.031) and, at a multiple regression analysis, it was predictive of reduced BMD, after correcting for the other CRFs, including depression levels (β =-0.03407, p=0.012, SE=0.012). Fig 2. Short Form Health Survey (SF-36) scores in accordance with HAMA tertiles of recruited postmenopausal women. Data are expressed as means ± SD. *=p<0.001 vs. HAMA-1; #=p<0.001 vs. HAMA-2.   APMB - Atti della Accademia Peloritana dei Pericolanti Classe di Scienze Medico Biologiche Vol. 105(2) 2017  ISSN 1828-6550   DOI: 10.6092 / 1828-6550 / APMB.105.2.2017.OS1  APMB - Atti della Accademia Peloritana dei Pericolanti - Classe di Scienze Medico-Biologiche (2017), 105(2):OS1(1-5)  DOI: 10.6092 / 1828-6550 / APMB.105.2.2017.OS1 Discussion Postmenopausal anxiety levels were significantly associated with fracture risk and DXA measurement of BMD. As known, anxiety has implications in some of the major human pathologies such as cardiovascular or cancer diseases may lead to reduced quality of life and possibly increased premature mortality [9,10]. Anxiety symptoms have been previously found in subjects with lower BMD and lower quantitative bone ultrasound measurements, the latter suggesting also a poor bone quality [3,11-14]. We suppose that the pathophysiological mechanism linking anxiety and bone loss may be due to immunological (e.g. increase of certain cytokines), endocrinological aspects (e.g. increase of cortisol), or via oxidative stress [15-20]. However, our aim was not the evaluation of molecular pathophysiology, thus it should be considered only a speculation. As self-reported life satisfaction has been longitudinally associated with reduced bone loss, we further suppose that poor perceived quality of life could affect bone health [21-23] and, in accordance with these data, our women falling in HAMA-3 showed a reduced quality of life as highlighted by SF-36 survey. Our preliminary results suggest a significant relationship between anxiety levels with BMD. Because osteoporosis represents a major public health problem, and because anxiety levels may be easily recognized, possibly enhancing fracture risk evaluation, physicians should evaluate also psychological aspects of women especially in postmenopausal age.  Conflicts of Interest: There is no potential conflict of interest, and the authors have nothing to disclose. This work was not supported by any grant.  References   1. Svedbom, A., Hernlund, E., Ivergård, M., Compston, J., Cooper, C., Stenmark, J., McCloskey, E.V., Jönsson, B., Kanis, J.A.,EU Review Panel of IOF (2013) Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 8:137. 2. Catalano, A., Morabito, N., Basile, G., Fusco, S., Castagna, G., Reitano, F., Albanese, R.C., Lasco, A. (2013) Fracture risk assessment in postmenopausal women referred to an Italian center for osteoporosis: a single day experience in Messina. Clin Cases Miner Bone Metab 10(3):191-194. 3. Williams, L.J., Bjerkeset, O., Langhammer, A., Berk, M., Pasco, J.A., Henry, M.J., Schei, B., Forsmo, S. (2011) The association between depressive and anxiety symptoms and bone mineral density in the general population: the HUNT Study. J Affect Disord 131(1-3):164-171. 4. Baxter, A.J., Scott, K.M., Vos, T., Whiteford, H.A. (2013) Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychol Med 43(5):897-910 5. Kanis, J.A., Johnell, O., Oden, A., Johansson, H., McCloskey, E. (2008) FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int. 19(4):385-397.  6. Hamilton, M. (1959) The assessment of anxiety states by rating. Br J Med Psychol 32(1):50-55. 7. Beck, A.T., Steer, R.A., Brown, G.K. (1996) Manual for the Beck Depression Inventory–II. San Antonio, TX: Psychological Corporation. 8. Ware, J.E. Jr, Sherbourne, C.D.(1992) The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. 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(2017) Bone health assessment by quantitative ultrasound and dual-energy x-ray absorptiometry in postmenopausal women with breast cancer receiving aromatase inhibitors. Menopause 24(1):85-91. 12. Atteritano, M., Lasco, A., Mazzaferro, S., Macrì, I., Catalano, A., Santangelo, A., Bagnato, G., Bagnato, G., Frisina, N. (2013) Bone mineraldensity, quantitative ultrasoundparameters and bone metabolism in postmenopausalwomen with depression. Intern Emerg Med 8(6):485-491. 13. Williams, L.J., Pasco, J.A., Jacka, F.N., Hodge, J.M., Kotowicz, M.A., Berk, M. (2013) Quantitative Heel Ultrasound (QUS) measures of bone quality in association with mood and anxiety disorders. J Affect Disord 146(3):395-400.  14. Catalano, A., Morabito, N., Di Vieste, G., Pintaudi, B., Cucinotta, D., Lasco, A., Di Benedetto, A. (2013) Phalangeal quantitative ultrasound and metabolic control in pre-menopausalwomen with type 1 diabetesmellitus. J EndocrinolInvest 36(5):347-251. 15. 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(2017) Pain in osteoporosis: from pathophysiology to therapeutic approach. Drugs Aging. doi: 10.1007/s40266-017-0492-4.     ©2017 by the Author(s); licensee Accademia Peloritana dei Pericolanti (Messina, Italy). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/).    Communicated and received November 15, 2107, revised December 4, 2017, published on line December 20, 2017  

Psychological factors may impacton postmenopausal women fracture risk

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Psychological factors may impacton postmenopausal women fracture risk

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