Depression Following Fracture in
Adults: A Comparative Study between Men and Women at a Tertiary Care
Centre
Sudheendra P.R.1,
Ramprasad K.S.2, Manjunath Rajashekharaiah2
1Dr Sudheendra PR, Assistant Professor, Department of Orthopedics,
Shimoga Institute of Medical Sciences, Shimoga, 2Dr Ramprasad KS,
Associate Professor, Department of Psychiatry, Shimoga Institute of
Medical Sciences, Shimoga, 2Dr Manjunath Rajashekharaiah, Junior
Resident, Department of Psychiatry, Shimoga Institute of Medical
Sciences, Shimoga. All are affiliated to Rajiv Gandhi University of
Health Sciences, Karnataka, India.
Address for
Correspondence: Department of Orthopaedics, SIMS,
District McGann Hospital Compound, Sagara Road, Shimoga-577201. E-mail:
drprsudhiortho@gmail.com
Abstract
Introduction:
Fractures are usually associated with functional impairment and
dependence; also bears psychological effect as the quality of life
decreases. Many studies have shown the presence of depression
associated with the fracture and hence the study was done to know the
same in our institution. Methods:
Inclusion criteria: Adults aged more than 35 years of both sexes who
had sustained fractures of long bones, hip and vertebral fractures who
were admitted as inpatients earlier, and requiring prolonged
rehabilitation. Exclusion
criteria: Severely medically ill patients. The mood state
was evaluated in patients with fractures after taking consent with
Beck’s Depression inventory. Follow up of inpatient with
fracture were done after their discharge. Results: This
study shows that among patients with fractures, higher prevalence of
moderate and severe depression is in females. Post-menopausal women are
most severely affected. Conclusion:
Postmenopausal females suffer more from depression associated with
fractures than males.
Keywords:
Hip fracture, Vertebral fractures, Long bone fractures, Depression
Manuscript received: 1st
July 2015, Reviewed:
10th July 2015
Author Corrected:
19th July 2015, Accepted
for Publication: 3rd Aug 2015
Introduction
The report on Global Burden of Disease estimates the point prevalence
of unipolar depressive episodes to be 1.9% for men and 3.2% for women,
and the one-year prevalence has been estimated to be 5.8% for men and
9.5% for women[1] 15% of elderly individuals report clinically relevant
symptoms of depression[2]. A metanalysis of 13 studies on epidemiology
of psychiatric disorders in Indian population reported prevalence of
depression to be 7.9 to 8.9 per thousand population and the prevalence
rates were nearly twice in the urban areas [3]. Prevalence of
depression in older people after hip fracture ranged from 9% to 47% and
largely exceed the 2% and 10% respectively reported for major and minor
depressive disorder in the aged-matched not affected people [4].
The lifetime risk of hip fracture is about 14 percent for
postmenopausal women and 6 percent for men [5]. Women with depression
were also more likely to suffer vertebral fractures than women without
depression. Women with depression did not have an increased rate of
wrist, humerus, or other fractures [6].
Etiopathogenesis of this association of depression in women and old age
has been evaluated. High levels of Cortisol are often found in
depressed individuals [7,8]. Higher cortisol levels in older adults
have been associated with a reduction in grip strength over a six year
period and standing and walking performance[9,10]. Also, the
cortisol:DHEAS ratio is higher in older hip fracture patients than in
healthy controls or younger comparable fracture patients[11,12].
Adrenocortical hormone balance may thus be a major determinant of
frailty in older hip fracture patients, particularly in those with
depression. Depression could lower bone mineral density through several
direct pathways. For example, persistently elevated plasma cortisol
levels have been associated with clinical depression [13]. Low bone
mineral density is suggestive of osteoporosis which is a predisposing
factor for fractures.
Similar pathogenesis in the association between long bone fractures and
depression can be anticipated. Correcting this ratio for example with
DHEA supplementation could benefit this patient population. Also, older
patients with depression have higher levels of the cytokine interleukin
6, indicating increased inflammatory activity, which may be linked to
increased bone resorption (or depressed patients may be more sedentary,
leading to increased resorption rates), thus increasing the risk for
hip fracture [14]. Depressive symptoms and major depressive disorder in
elderly persons after a stressful medical event like a hip fracture may
be associated with 5-HTTLPR genotype. Subjects with an s allele
(genotype s/l or s/s) had significantly higher Ham-D scores over 14
weeks of follow-up than those with the l/l genotype [15].
Most of the studies in this regard have been done in western
population. A study in this regard comparing the two genders in the
Indian population has not come to the study group’s
attention. Given the impact of the gender differences in the functional
recovery affecting the therapeutic and rehabilitative decision making
from fractures, the need for this study to compare the incidence of
depression in males and females suffering from fractures was evident to
the study team.
Material
and Methods
Inclusion criteria:
Adults aged more than 35 years who had sustained fractures of long
bones, hip and vertebral fractures who were admitted as inpatients
earlier, and requiring prolonged rehabilitation.
Exclusion criteria:
Severely medically ill patients. Their mood states were examined using
Beck’s Depression inventory [16] This was a prospective study
done between April 2015 to July 2015 using continuous sampling method.
Statistical analysis was done using the SPSS 21.0 version.
Results
70 subjects were included in the study after obtaining their consent.
Out of 70 subjects, 40 were male and 30 were female.
Table 1: Gender
distribution with severity of Depression
|
|
Gender
|
Total
|
|
Male
|
Female
|
|
depression
|
Normal
|
Frequency
|
20
|
5
|
25
|
|
%
|
50.0%
|
16.66%
|
35.7%
|
|
Mild depression
|
Frequency
|
10
|
8
|
18
|
|
%
|
25.0%
|
26.66%
|
25.7%
|
|
Moderate depression
|
Frequency
|
8
|
12
|
20
|
|
%
|
20.0%
|
40.0%
|
28.6%
|
|
Severe depression
|
Frequency
|
2
|
5
|
7
|
|
%
|
5.0%
|
16.66%
|
10%
|
|
Total
|
Frequency
|
40
|
30
|
70
|
|
%
|
100.0%
|
100.0%
|
100.0%
|
|
Chi-square=10.085
|
Df=3
|
p-value=0.018
|
|
Table 1 depicts the association of severity of depression
and its gender distribution highlighting the higher prevalence of
severe depression in female gender in the study population.
Table: 2 : Comparing age
and gender in patients with fracture associated with depression
|
|
<65yrs
|
>65yrs
|
|
Male
|
14
|
06
|
|
Female
|
17
|
08
|
Table 2 shows the distribution of fractures across the age
and gender among the depressed patients. 30% of the male gender sample
and 32% of female gender sample are >65 yrs, showing the high
prevalence of depression with associated fractures in the elderly
female population.
Discussion
Depression has been shown to be more common in women who are suffering
from fractures than those who are not. This is reported especially in
older age group [17]. A Metaanalysis noted that depression was
associated with a 17% - 52% increase in fracture risk. Also, it found
an association between depression and increased risk of fracture and
bone loss that may be mediated by antidepressants [18]. High depressive
symptomatology remained predictive of hip fracture. A study gave
evidence of a prospective association between depression and hip
fracture[19]. In a five-year study of all fractures among [7,518] older
women, depressed women had a rate of hip fracture 40 percent higher
than women who were not depressed[20] It was further found that higher
number of diabetic macro-vascular complications and hip fracture is
significantly associated with a higher risk of depression onset in
elderly diabetes[21]. Individuals with clinical evidence of apathy are
at high risk for developing MDD [22]. High disability[23] poor physical
function[24] falls[25,26] and low bone density[27] have been associated
with depression. All these increase susceptibility to osteoporotic
fractures[28] Older individuals who are depressed may also be at
increased risk for falls and fracture due to the effects of
antidepressants or sedatives[29,30]. Patients with depression have
poorer recoveries following fractures [31].
We found that women suffered from moderate (40%) and severe depression
(16.66%) more than men (20% and 5% respectively). Men were found to
have more of mild depression (25%) or had no mood symptoms (50%) at
all. Also, we found that among the depressed patients 30% of the male
and 32% of female are above 65 yrs, showing the higher prevalence of
depression with associated fractures in the elderly population.
In agreement with our findings, it has been seen that men recovered
from depressed mood better than women during the rehabilitation from
hip fractures. Gender differences in functional recovery may affect
therapeutic and rehabilitative decision making [32]. Some studies have
shown that depressive symptoms can complicate the course of
rehabilitation and affect functional recovery at discharge [33,34] but
other studies have shown no association of the psychological parameter
with the recovery [35,36,37].
The life time risk of fracture in women is 40-50% and 13-22% in men
[38]. A decline in quality of life has been shown following fracture
regardless of its site producing substantial social and medical costs
[39]. Another study showed that fracture is associated with poor
psychological and physical health, resulting in physical dependence and
hence lack of independence [40,41]. In a review it was showed that post
injury depressive symptoms are common following hip fractures which are
predictor of poor recovery in the old [40]. It appears that a two way
relationship exists between depression and fracture. The pre-injury
mood state and post fracture depression has an impact on the recovery
from fracture in the elderly, while a failure to regain original
pre-injury functional levels may be the cause of persistence of the
depressed mood state [41].
There were many limitations in our study which can be addressed in
later studies. Studying the individual fractures with the depressive
symptoms was not done. This could throw more light on the differences
between the effect of hip fractures and other long bone fractures on
depression. Short duration of follow up, not accounting the family
history of psychiatric illness or the past history of psychiatric
illness were other limitations. As is already known, family history and
past history are independent risk factors on the individual’s
potential to develop depressive symptoms. These can be confounding
factors. Yet another limitation is the lower number of sample which
makes it difficult for us to generalize the findings of the study. Also
we have not taken into account other medical co-morbidities that may
co-exist with fractures and might have had confounding effect.
Although clear standards exist for the medical management of hip
fracture, little attention has been given to depression and hip
fracture [42]. Because of the close association of depression with
lower bone mineral density, the advantages of including calcium
supplementation in the management of depression should be considered.
Educating primary care physicians to recognize and treat or refer
depressed older adults may help reduce the incidence of hip fracture.
Apart from diagnosis and treating depression before and after
fractures, psychiatrists can assist the patient in adapting to and
coping with fractures and its sequelae. Supporting the patient in
accepting temporary dependency and role changes of the patients and
their families form a part of it. Empathetic listening, building a
support network, Positive reinforcement and counselling, occupational
therapy and devising coping strategies were found to improve depressed
patients with hip fractures in a study [43].
For the depressed older adult confined indoors, the benefit of calcium
plus vitamin D supplementation as well as treatment of depression can
be evaluated. It is important to remember that all psychotropics may
increase the risk of falls. Therefore, clinicians must continue to
assess gait and stability while considering to titrate the dose of
psychotropics, especially when patients are encouraged to increase
physical activity.
Hormone replacement and calcium supplementation lower the risk of hip
fracture among depressed older women. Two treatable baseline
characteristics, postoperative pain and baseline anxiety were the
strongest independent risk factors for Incident depression. Addressing
these treatable symptoms could therefore be protective against
fractures in this high risk group.
Conclusion
It was found that females suffer more from depression associated with
fractures than males in our study. The postmenopausal women were found
to be more commonly affected with depression. The causative and
influencing factors other than age and sex need to be further studied.
Funding:
Nil, Conflict of
interest: None initiated.
Permission
from IRB:
Yes
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How to cite this article?
Sudheendra PR, Ramprasad KS, Manjunath Rajashekharaiah. Depression
following fracture in adults: Comparative study between men and women
at a tertiary care centre. Int J Med Res Rev 2015;3(7):706-711. doi:
10.17511/ijmrr.2015.i7.133.