Predicting Acute Anxiety and Depression following Hip Fracture

Journal of Behavioral Medicine, Vol. 30, No. 2, April 2007 ( C 2007) DOI: 10.1007/s10865-006-9088-x Predicting Acute Anxiety and Depression following Hip Fracture Leyna Bruggemann, 1 Reginald D. V. Nixon, 1,2 and Tamara Cavenett 1 Accepted for publication: November 7, 2006 Published online: January 25, 2007 The role of injury-related beliefs and hopelessness on depression and anxiety in the acute phase following hip fracture was investigated in 103 hip fracture patients. Participants were assessed at two time points: as inpatients within one week of their surgery, and then 3-weeks later as outpatients. Abramson et al. s (1989) theory of hopelessness-related depression was investigated as a possible explanatory model to account for depression following hip fracture. Results indicated that hopelessness mediated the relationship between beliefs regarding personal control and depression at the second assessment. Anxiety at follow-up was predicted by control beliefs whereas physical mobility, acute stress and pain made no significant contribution. This study is the first to provide tentative evidence that post-injury beliefs and hopelessness influence levels of depression and anxiety in hip fracture patients in the acute phase of their injury, and indicates that further study in this area is warranted. KEY WORDS: anxiety; depression; hopelessness; hip fracture; injury cognitions. INTRODUCTION In ageing Western societies, the incidence of hip fractures is increasing (Chipchase et al., 2000; Cummings et al., 1990). In the United States, there were approximately 340,000 hospital admissions for hip fractures during 1996 (Graves and Owings, 1998), and in Australia, the number of hip fractures is predicted to increase by approximately 66% by 2021 (Chipchase et al., 2000). Quality of life postfracture can be affected by a number of factors, and includes physical and mental rehabilitation (Billig et al., 1988; Holmes and House, 2000; Lieberman et al., 1999). Although hip fracture is treatable, fewer than half of the sufferers return to their pre-fracture mobility (Swantek and Goldstein, 2000), frequently due to pre-existing and post-operatative depression and cognitive impairments such as dementia and delirium (Billig et al., 1988; Holmes and House, 2000; Magaziner et al., 1990). 1 School of Psychology, Flinders University, Australia. 2 To whom correspondence should be addressed at School of Psychology, Flinders University, Australia; e-mail: reg.nixon@ flinders.edu.au. A number of factors impede accurate estimates of depression and anxiety following hip fracture, including the use of mixed medical samples, varying assessment measures, and time of assessment. At present, varying rates of anxiety and depression in hip fracture patients have been reported, typically, between 14 39% (Billig et al., 1988; Bond et al., 1998; Muller-Thomsen et al., 2002). An exception to these figures is the report by Dorra et al. (2002) that depression and anxiety in elderly hip fracture inpatients is uncommon. These authors reviewed patient hospital charts for the presence of behaviors indicative of depression and anxiety as documented by hospital staff. Dorra et al. (2002) conceded, however, that it was likely that rehabilitative staff may not have been aware of what constituted depressive or anxious behavior as documentation of such was relatively uncommon (p. 256). The psychological consequences of hip fracture injuries has not been an area of systematic investigation; rather research has typically only examined psychological states in terms of their influence on physical outcome (e.g., Cummings et al., 1988; Dorra et al., 2002; Magaziner et al., 1990; Mossey et al., 97 0160-7715/07/0400-0097/0 C 2007 Springer Science+Business Media, LLC

98 Bruggemann, Nixon, and Cavenett 1990; Roberto, 1992). There is increasing recognition of the role of beliefs, frequently labeled illness perception, in psychological adjustment within health populations (Cameron and Moss-Morris, 2004). For example, Murphy et al., (1999) found that sufferers of rheumatoid arthritis who viewed their illness as serious and uncontrollable were more likely to experience depression, even when the level of physical disability was controlled. Similarly, illness perceptions have been observed to be associated with poorer mental health in samples of patients with Addison s disease (Heijmans, 1999) and psoriasis (Scharloo et al., 2000). Initial perceptions following medical events have also been shown to predict recovery. In myocardial infarction patients, those who believed their illness to have less serious consequences and who believed they had some control over their illness returned to work earlier (within 6 weeks) and were more likely to attend rehabilitation courses (Petrie et al., 1996). Interestingly, anxiety has largely been overlooked in studies that specifically measure illness perceptions, but evidence from longitudinal studies involving cardiac patients has suggested that perceived control might contribute to a reduction in anxiety and depression (Anderson, 1987; Taylor et al., 1991). Taylor et al. (1991) found that beliefs in personal control appear to reduce both depression and anxiety, and more specifically, contribute to a reduction of anxiety acutely and longitudinally. The longitudinal nature of these studies supports the proposition that feelings of control influence anxiety and depressive symptoms, not the other way around. At this time, however, no specific theoretical model exists to account for the development of anxiety and depression following hip fracture. A diathesis-stress model is argued to best describe the etiological pathway of hopelessness to depression (Abramson et al., 1989) and has a potential application to a hip fracture population. In such a model the occurrence of negative life events is followed by the individual making negative inferences about this situation, themselves and/or their future that then leads to hopelessness. Hopelessness is more likely to occur if the inferences individuals make are stable and global (enduring and widespread), are believed to contribute to future negative consequences, or if they imply negative characteristics about themselves, leading to depression (Abramson et al., 1989; Alloy and Clements, 1998). Given the potentially lifechanging consequence of hip fracture (e.g., inability to continue to live independently etc), such an event can be seen as a significant stressor. Following this, and if individuals made negative inferences about the injury (hitherto labeled injury beliefs ), in particular in relation to personal control and consequence of the injury, the model would predict these individuals would be more likely to experience hopelessness and depression. Thus hopelessness is argued to mediate the relationship between injury beliefs and depression. Although hopelessness has been found to predict depression concurrently and prospectively in the literature, as have injury beliefs (Alloy and Clements, 1998; Murphy et al., 1999; Rholes et al., 1985), it has not been specifically examined in hip fracture patients. Hopelessness, however, would not be expected to predict anxiety. Rather, given the potentially traumatic experience of hip fracture, it is more likely that fear at the time of injury and injury beliefs would have a direct relationship with anxiety. Not only have predictors of psychological adjustment following hip fracture been understudied, so too has the acute course of emotional responses. The possibility that acute responses within days of injury might predict later adjustment has not been examined. Given that patients in Australia are typically discharged within a week of admission following hip fracture, this period provides a window of opportunity for brief screening of illness perceptions and mood. Considering that research to date on hip fracture frequently relies on a single assessment, and that mood states may change over time, a short-term follow-up appears justified since it is unclear whether predictors of depression and anxiety are stable in the immediate aftermath of the injury, for example, during hospitalization after the injury, or whether they might fluctuate in the days and weeks following injury. In summary, psychological adjustment following hip fracture has been understudied and no investigation of changes in psychological adjustment in the acute interval post-fracture has been conducted. The present study had several aims. First, to document the prevalence of anxiety and depressive symptoms in the days following hip fracture. Second, to conduct a brief follow-up (3-weeks after the initial assessment) to track potential fluctuation in mood states. Third, to test the proposal that hopelessness mediates the relationship between injury beliefs and depression, and that fear and injury beliefs have an independent relationship to anxiety in these individuals.

Anxiety, Depression, and Hip Fracture 99 METHOD Participants A final sample of 103 participants with a mean age of 78.04 (SD = 11.29) who were orthopaedic inpatients admitted to the Flinders Medical Centre following a hip fracture were recruited, of whom 79% (n = 81) were female. Participants were interviewed on average 5.03 days following surgery (SD = 3.69). Participants were excluded if hip fracture was non-traumatic (i.e., disease-related), they had dementia, active psychosis, intellectual impairment, moderate-to-severe brain injury, were not proficient in English literacy, and/or were actively suicidal. Of the 279 patients that were admitted to the hospital with a hip fracture during the study period, 131 were suitable to be approached. Of those excluded, 108 had dementia, 11 had language difficulties, 4 had an intellectual impairment, 4 were unable to communicate (deaf and blind or expressive dysphasia), 10 had suffered a non-trauma related pathological fracture caused by cancer or osteoporosis, and 11 were judged by nursing staff to be too physically unwell to be approached. Twenty-eight suitable candidates declined to participate. Procedure Following written informed consent, demographic information was obtained and self-report measures of anxiety, depression, injury beliefs and pain were administered verbally by L.S.B. Verbal administration was deemed appropriate as the response sets of each questionnaire changed, which at times made the questionnaires difficult to answer if clarification was not provided. The same measures were administered via telephone 3-weeks after the initial assessment, as was a measure of physical mobility. Measures Depression Anxiety Stress Scale (Lovibond and Lovibond, 1996) The anxiety and depression scales from the short-form version were used. This 14-item measure consists of seven depression and anxiety statements rated on a 4-point Likert-type scale (did not apply to me at all to applied to me most of the time) for the past week. Examples of items are: I felt down-hearted and blue and I felt close to panic. The total score for each scale was used. The scale has good temporal stability over 2-weeks, ranging between.71.81 (Brown et al., 1997) and has strong convergent and discriminant validity with measures such as the Beck Depression Inventory (Beck and Steer, 1987) and Beck Anxiety Inventory (Beck and Steer, 1993). It has recently been restandardized on a large sample (Crawford and Henry, 2003), and Cronbach s alphas have been reported between.84 (anxiety) and.95 (depression). Internal consistency scores for the current data were calculated at.81 for depression and.63 for anxiety. Beck Hopelessness Scale (Beck and Steer, 1988) The scale consists of 20 true/false items that are scored dichotomously. Some examples from the measure are My future seems dark to me and I can look forward to more good times than bad times (reverse scored item). The internal consistencies range from.82 to.93 in clinical samples, and test-retest reliability over 6-weeks is reported to be.66 (Beck and Steer, 1988). The internal reliability score from the data in the current study was.70. Revised Illness Perception Questionnaire (Moss-Morris et al., 2002) Based on previous research findings, the two subscales most associated with negative mood from the measure, Consequences and Personal Control, were used from the nine possible subscales. Each subscale consists of 6 items. Example items for the scales are as follows; Consequence: My injury has major consequences on my life, My injury strongly affects the way others see me ; Personal Control: What I do can determine whether my injury gets better or worse, Nothing I do will affect my injury (reverse scored item). A 5-point Likert-type scale response set for the subscales was used ranging from strongly agree to strongly disagree, and mean scores are reported. Cronbach s alphas for the present study were.79 for Personal Control and.69 for Consequences. Acute Stress Disorder Scale (Bryant et al., 2000) This questionnaire was used to measure specific anxiety symptoms associated with a traumatic event.

100 Bruggemann, Nixon, and Cavenett Although the event itself would not normally be sufficient to cause a disorder such as acute stress disorder, it is not uncommon for medical events to result in posttraumatic-type symptoms (Kangas et al., 2002). The measure is a 19-item questionnaire that uses a 5-point Likert-type scale (with responses ranging from not at all to very much). It includes items such as Have memories of the trauma kept entering your mind? and Have you become more alert to danger since the trauma?. Bryant et al. (2000) report that the measure has an internal consistency of.96, and test-retest reliability of.94 (over 2 7 days). In the present study, internal reliability was found to be.82. Pain A rating of the average amount of pain the participant had been experiencing was obtained using a 10-point Likert-type scale (1 = none,10 = extreme) at both Time 1 (since they had been in hospital) and Time 2 (since their first assessment). Physical Mobility Physical mobility was measured at the second assessment using an adaptation of the instrument devised by Cummings et al. (1988) for hip fracture patients. The 10-item questionnaire asked the participants to indicate their difficulty in performing functional tasks involving weight-bearing on their hip, for example: walking a short and a long distance, getting on and off the toilet, washing and drying both feet. Ability to perform these functions was measured by a 5-point Likert-type scale where 0 = unable to do, 1 = a lot of assistance needed, 2 = a moderate amount of assistance needed, 3 = a little assistance needed, 4 = perform with no difficulty. The mean score for the sum of these items was 15.67 (SD = 8.05), with scores ranging between 0 36, and internal reliability for the scale was.81. RESULTS Data were screened for normality and outliers according to Tabachnick and Fidell (2001). Although several variables were slightly skewed, their transformation did not alter the pattern of any findings hence the original raw data is reported. Data analysis consisted of paired t tests to investigate changes in symptoms over time, and multiple regression was used to (a) test mediational hypotheses, and (b) to examine which factors contributed to the prediction of anxiety and depressive symptoms at follow-up. Participant Summary Of the 103 that participated at the Time 1 assessment (T1), 64% (n = 66) took part in the follow-up approximately three weeks later (M = 23.20 days, SD = 3.17). Three participants did not complete the T1 assessment due to fatigue or distress. Reasons for not participating at the Time 2 assessment (T2) were: 2 declined to participate in the follow-up at T1, 1 had died, 10 were too cognitively disorientated, 11 stated that they were too unwell and 3 were unable to be contacted. Participants who did not participate in the T2 assessment had significantly higher hopelessness scores at T1 than those interviewed at T2, t(95) = 2.22, p =.029. The two groups did not differ either in terms of demographics or any other variables. Prevalence of Anxiety and Depression Symptoms and Change in Mood Over Time The means and standard deviations (SDs) of the variables of interest are presented in Table I. A Bonferroni correction for multiple tests was applied, with p values of.007 or below considered significant (α =.05/7). Generally, most variables remained stable. Thus participants reports of hopelessness, depression, acute stress symptoms and injury beliefs did not change over time, whereas only anxiety and pain ratings significantly decreased over the 3-week interval. Of interest is that at the initial assessment there was a relatively low level of depression and a comparatively high level of anxiety reported by the participants (Table II). Thus it can be seen that using Crawford and Henry s (2003) cut-offs, 77% of individuals reported levels of depression in the normal range, whereas only 28% of participants were in the normal range for anxiety. Consistent with the change results reported above, these proportions remained stable for depression, but some fluctuation was demonstrated in terms of anxiety, with 52% of participants falling within the normal range at the second assessment. Self-reported hopelessness was generally low, with 53% and 69% of participants reporting minimal levels respectively at the two assessments.

Anxiety, Depression, and Hip Fracture 101 Table I. Means, Standard Deviations and Significance of Change for Variables at Time 1 and Time 2 T1 T2 Variable M SD M SD t df p d Depression 2.67 2.90 2.93 3.22 0.70 60.489 0.08 Anxiety 4.58 3.41 2.92 2.70 3.66 59.001 0.54 Personal control 3.95 0.68 3.90 0.63 0.51 57.612 0.08 Consequence 3.24 0.70 3.17 0.66 0.69 57.491 0.10 Hopelessness 3.44 2.60 3.50 3.77 0.13 53.897 0.10 Acute Stress 28.49 8.87 27.43 10.01 1.15 52.257 0.11 Pain 5.95 2.15 4.38 2.78 4.73 64.000 0.64 Note. Depression: Depression Anxiety Stress Scale Depression subscale; Anxiety: Depression Anxiety Stress Scale Anxiety subscale; Personal control: Revised Illness Perception Questionnaire Personal control beliefs subscale; Consequence: Revised Illness Perception Questionnaire Consequence beliefs subscale; Hopelessness: Beck Hopelessness Scale; Acute Stress: Acute Stress Disorder Scale; Pain: average pain experienced (1 = none, 10 = extreme). Prediction of Depression and Anxiety at Follow-Up Depression The proposal that hopelessness mediated the relationship between injury beliefs (consequences and control) and depression at the second assessment was tested as outlined by Baron and Kenny (1986). In the case of a injury belief-hopelessness-depression model, injury beliefs should predict hopelessness, and then (separately) injury beliefs should predict depression. Mediation is tested in the final analysis when injury beliefs and hopelessness are used simultaneously to predict depression. If hopelessness mediates the relationship between injury beliefs and depression, the significant relationship between injury beliefs and depression is reduced because the effect of hopelessness is now controlled. Testing the significance of the mediated effect was carried out as set out by Goodman (1960) with a z-score calculated by dividing the mediated effect by its standard error and significance established using traditional z tests (critical value 1.96). However consequence cognitions were not correlated with the hypothesized mediator - one of the necessary preconditions for mediation thus its predictive value was examined through multiple regression (reported later), and not through mediation analyses. However personal control beliefs met the conditions of mediation, and analyses were conducted to examine whether hopelessness mediated the relationship between these beliefs and T2 depression after controlling for T1 depression symptoms, and T2 pain ratings and physical mobility. Gender and age were unrelated to anxiety or depression, thus were not controlled in any analyses. As seen in Table III, although personal control beliefs predicted depression severity when entered alone, this relationship became nonsignificant when hopelessness scores were entered and this mediated effect was significant (z = 2.09), indicating full mediation. Table II. Proportion of Participants Experiencing Normal, Mild, Moderate, Severe and Extremely Severe Levels of Depression, Anxiety and Hopelessness at Time 1 and Time 2 Variable Normal Mild Moderate Severe Extremely severe T1 Depression 77 (77) a 9(9) 8(8) 4(4) 2(2) T2 Depression 73 (44) 11 (7) 11 (7) 5 (3) T1 Anxiety 28 (28) 45 (45) 7 (7) 14 (14) 6 (6) T2 Anxiety 52 (31) 23 (14) 20 (12) 3 (2) 2 (1) Minimal Mild Moderate Severe T1 Hopelessness 53 (51) 38 (37) 9 (9) T2 Hopelessness 69 (38) 16 (9) 15 (8) Note. Severity levels for Anxiety and Depression determined by Crawford and Henry s (2003) cut-off values. Severity levels for Hopelessness determined by Beck and Steer s (1993) cut-off values. Depression = Depression Anxiety Stress Scale Depression subscale; Anxiety = Depression Anxiety Stress Scale Anxiety subscale; Hopelessness = Beck Hopelessness Scale. a Numbers in parentheses represent the n values for each percentage value.

102 Bruggemann, Nixon, and Cavenett Table III. The Mediating Effect of Hopelessness on the Relationship Between Personal Control Beliefs and Depression Symptoms Variable β p Adjusted R 2 Overall Model F p Regression 1: Personal control predicting.29.024.30 F(4, 47) = 6.39.000 hopelessness Regression 2: Personal control predicting.23.039.43 F(4, 52) = 11.73.000 depression Regression 3: Personal control and hopelessness predicting depression Personal control.07.495 Hopelessness.43.001.55 F(5, 46) = 13.45.000 Note. Personal control: Revised Illness Perception Questionnaire Personal control beliefs subscale; Hopelessness: Beck Hopelessness Scale; Depression: Depression Anxiety Stress Scale Depression subscale. Using hierarchical multiple regression, the independent contribution of consequence beliefs to depression at the second assessment was examined. Consequence beliefs and depression at T1 were entered on the first step, T2 pain ratings and physical mobility were entered on the second step, and consequence beliefs at T2 were entered at the final step. Depression at T1 and pain at time T2 were significant predictors of T2 depression at Step 1 and Step 2 respectively, and there was a nonsignificant trend for physical mobility to predict T2 depression at Step 2 (p =.051). Similarly there was a nonsignificant trend (p =.08) for consequence beliefs, which was entered on the final step, to account for additional variance of depression scores (see Table IV). Depression at T1 remained a significant predictor of later depression scores in this final step. Disorder Scale scores). T1 control and consequence beliefs, anxiety and acute stress were controlled at Step 1, with T2 pain, mobility and acute stress entered at Step 2, and T2 control and consequence beliefs entered on the final step so that their independent contribution could be investigated. As indicated in Table V, although the models were significant at Step 1 and 2, no individual variable uniquely predicted anxiety symptoms at T2. The final model was significant, with beliefs uniquely accounting for 13% of the variance at Step 3, however examination of the regression coefficients indicated that personal control beliefs were the only contributing variable in this final step. Consistent with the depression findings, it was those individuals who felt that they had control over their injury who appeared to experience reduced anxiety at follow-up. Anxiety Both personal control and consequence cognitions were examined to test the hypothesis that anxiety at the second assessment would be predicted by these beliefs and fear-type anxiety (Acute Stress DISCUSSION Approximately one month following injury, 16% and 25% of the sample had moderate or higher levels of depressive and anxiety symptoms respectively. Whereas these measures remained relatively Table IV. The Effect of Consequence Beliefs on Depression Symptoms at Follow-Up Variable β p Adjusted R 2 Overall Model F p Step 1.30 F(2, 54) = 12.79.000 Consequence beliefs (T1).00.98 Depression (T1).57.000 Step 2.39 F(4, 52) = 9.76.000 Pain rating (T2).23.038 Physical mobility (T2).22.051 Step 3.41 F(5, 51) = 8.79.000 Consequence beliefs (T2).21.078 Note. Consequence: Revised Illness Perception Questionnaire Consequence beliefs subscale; Depression: Depression Anxiety Stress Scale Depression subscale; Pain rating: average pain experienced (1 = none, 10 = extreme); Physical mobility: physical mobility scale.

Anxiety, Depression, and Hip Fracture 103 Table V The Effect of Personal Control and Consequence Beliefs on Anxiety Symptoms at Follow-Up Variable β p Adjusted R 2 Overall Model F p Step 1.14 F(4, 45) = 2.90.032 T1 Anxiety.15.367 T1 Consequence beliefs.04.791 T1 Personal control beliefs.19.175 T1 Acute stress.31.089 Step 2.21 F(7, 42) = 2.81.017 T2 Pain rating.12.395 T2 Physical mobility.25.086 T2 Acute stress.20.417 Step 3.32 F(9, 40) = 3.61.002 T2 Consequence beliefs.18.253 T2 Personal control beliefs.41.004 Note. Anxiety: Depression Anxiety Stress Scale Anxiety subscale; Consequence: Revised Illness Perception Questionnaire Consequence beliefs subscale; Personal control: Revised Illness Perception Questionnaire Personal control beliefs subscale; Acute Stress: Acute Stress Disorder Scale; Pain rating: average pain experienced (1 = none, 10 = extreme); Physical mobility: physical mobility scale. stable for depression and most other variables, there appeared to be an improvement in anxiety symptoms and pain ratings relative to the first assessment. When mild levels of symptoms are taken into account, our finding that 27% of individuals reported depressive reactions is consistent with that reported by Billig et al. (1988) who found 28% of hip fracture patients in the acute stage of their injury had elevated depressive symptoms. On the other hand we observed higher levels of mild-to-severe anxiety symptoms than a more recent study (Bond et al., 1998), which reported the prevalence of anxiety to be 24%, however it is likely that the differences in the interval between injury and follow-up assessment (one month in our study, 6-months in Bond et al.) contributed to this discrepancy. Our findings are also in contrast to the conclusion by Dorra et al. (2002) that anxiety and depression amongst hip fracture inpatients is uncommon. It is also worth noting that unlike some instruments, our depression measure did not contain items that index physical symptoms, thus we do not believe these levels were affected by this potential confound. It was also of interest that scores on the acute stress measure were approximately 0.5 SD lower than the mean scores reported by victims of motor vehicle accidents and assaults who did not develop acute stress disorder (Bryant et al., 2000). This suggests that while stressful, hip fracture in this sample did not cause the level of traumatic anxiety seen in those who develop a significant trauma response following other types of potentially life changing events. The hypothesis that hopelessness would mediate the relationship between injury beliefs and depression was partially supported in that personal control beliefs but not consequence beliefs played a mediating role. Similarly, after controlling for initial symptom severity and pain, personal control beliefs remained a unique predictor of anxiety at follow-up, and that like depression, less control was associated with higher levels of anxiety. The current findings are in accord with accumulating evidence that individuals perceptions of their health influence both psychological and physical outcomes (Cameron and Moss- Morris, 2004; Heijmans, 1999; Petrie et al., 1996; Scharloo et al., 2000). For this hip fracture sample, beliefs regarding control rather than consequences of the injury appeared to be associated with anxious and affective symptomatology. While it is possible that the lower internal reliability of the consequence cognition subscale contributed to this discrepancy, it may also be that in the acute period following hip fracture, concerns about how the injury will heal are dominant, and that concerns regarding the consequence of the injury might become more relevant over a longer follow-up period. It is nonetheless interesting that control beliefs influenced symptoms in this particular group. In contrast to other health populations where the course of disease can be unpredictable (e.g., rheumatoid arthritis, psoriasis), there often can be a reasonably predictable trajectory of healing following fracture. Despite this, the current data shows that a sense of uncontrollability was associated with the experiencing of increased anxiety and depressive symptoms. We believe the present study significantly contributes to an understudied area. First, this sample demonstrated elevated levels of depressive and

104 Bruggemann, Nixon, and Cavenett anxiety symptoms in the first month following hip fracture. The observation that depression levels shortly after surgery are stable in the first month following injury suggests that this is a period of opportunity to screen patients, and therefore supports earlier calls for such screening and early intervention (e.g., Mossey et al., 1990). Second, our results indicate that it is those who believe they have little control over their injury who are at risk of hopelessness and depressive symptoms. Although replication is clearly necessary, this finding points to a possible area for psychological intervention. Third, affective states in hip fracture patients have previously only been studied in the context of their impact on physical recovery. To our knowledge, this is the first study to examine cognitive predictors of anxiety and depression in this population. It is interesting to note, however, that in the present study affective states were unrelated to physical outcome in contrast to previous research (e.g., Dorra et al., 2002; Magaziner et al., 1990; Roberto, 1992). The present study has limitations. Our results can only be generalized to English-speaking hip fracture patients who are cognitively intact. Similarly, the ethnic/racial composition of the sample was not measured, thus its influence on the findings is unknown. We concede there was substantial attrition in the study that employed only a short follow-up. Our rate of 36% was somewhat comparable to the 30% reported by Bond et al. (1998), although the latter was over a 6-month interval. We recognize that affective states were measured by self-report questionnaires, and that the levels of anxiety and depression reported did not represent clinical diagnoses. Similarly, premorbid psychological functioning was not measured. 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