An osteoporosis diagnosis may affect a patient’s mental health because of diminished quality of life, fear of falling, embarrassment about posture changes, or general depression about the diagnosis; however, several recent studies have found that mental health disorders may significantly affect bone loss, contributing to osteoporosis.

Although osteoporosis and psychological stress occur via different mechanisms, several potential molecular links exist between a pathological response to stress and the development of bone disease. Anxiety has been found to contribute to lower hip bone mineral density (BMD), and several studies have shown that depression is a predictor for osteoporosis and fracture. Also germane to the discussion is that pharmacological interventions designed to improve mental health, such as those for major depressive disorder or posttraumatic stress disorder, may affect bone health.1

In one study, postmenopausal women with depression presented with lower lumbar vertebra and femur dual-energy X-ray absorptiometry scores when compared with women without depression.2 Another study compared the bones of 2327 patients with depression with 21,141 patients without depression. The patients with depression had lower BMD and higher bone resorption markers than the patients without depression. In fact, lower BMD was observed in the vertebra, proximal femur, and distal radius, and was found to involve multiple trabecular bone sites throughout the body.3

Sex, Stress, and Osteoporosis

Studies involving both sexes have revealed a negative association between depression and BMD.2 More specifically, researchers have found that women are more sensitive to stress, and depressed women, in particular, respond more strongly to stressors. Both osteoporosis and depression are ~3× more common in women than in men, and women are more vulnerable to depression-related low bone mass.3

Several studies have examined the relationship between osteoporosis and depression in men. In a study of 80 patients with depression, about one-third of which were men, the spinal BMD was 15% lower than in the control participants. In general, studies showed that bone mass was lower in men with depression when compared with men without depression, and bone loss in men with depression was greater than in women with depression.3

A Closer Look at the Link

Bone tissue is continuously lost and regenerated to maintain a healthy balance and adapt to changing environmental factors. Disturbances in these processes can result in reduced bone mass and an increased risk for fractures. The aging process, particularly in postmenopausal women, further affects bone health.2

Stressful situations can provoke physiological responses, and each person responds differently to these situations, depending on their interpretation, resources, and adaptation strategies.2 Psychological or mental stress can occur in response to an acute event, as in a fight-or-flight response to a traumatic or life-threatening event, or it can be chronic, as in the case of caregivers, service members, and other high-stress occupations.

In times of acute psychological and physical stress, stress signaling begins through the hypothalamic-pituitary-adrenal (HPA) axis and the sympathomedullary pathway through the secretion of stress hormones, which include glucocorticoids (cortisol) and catecholamines (epinephrine and norepinephrine). Immune cells (leukocytes) release receptors for these stress hormones and quickly respond by altering the inflammatory immune response; however, in chronic stress and chronic stress-associated mental health conditions, the HPA axis becomes poorly regulated, resulting in hypercortisolism or glucocorticoid resistance.1

This article originally appeared on Rheumatology Advisor