Journal of Research in Medical Sciences1735-19953169202609021176411764EN20260902<p><strong>Background:</strong> Evidence on depressive symptoms and skeletal health is largely cross-sectional and rarely addresses competing risk, dose-response, or potential behavioral pathways. We examined the association between baseline depressive symptoms and incident osteoporosis in older adults, accounting for competing mortality and exploring mediation by physical activity.</p><p><strong>Materials and Methods:</strong> We analyzed 4920 adults aged ? 60 years from the English Longitudinal Study of Ageing with Wave 1 8?item Center for Epidemiologic Studies Depression Scale (CES?D?8) scores and follow?up osteoporosis ascertainment. Incident<br />physician?diagnosed osteoporosis was the outcome. Cox models estimated hazard ratios (HRs) per 1?point higher CES?D?8 score. Restricted cubic splines assessed dose?response, Fine–Gray models accounted for death as a competing event, and exploratory  atural?effects models assessed baseline physical activity as a potential mediator.</p><p><strong>Results:</strong> During a median follow?up of 16.0 years, 502 participants developed incident osteoporosis and 1138 deaths occurred. Higher CES?D?8 scores were associated with greater<br />osteoporosis risk in the fully adjusted Cox model (HR, 1.05; 95% confidence interval [CI], 1.01–1.10; P = 0.020), with consistent results in Fine–Gray models (subdistribution HR, 1.05; 95% CI, 1.01–1.10; P = 0.019). The dose–response appeared approximately<br />linear. Exploratory subgroup analyses did not show robust effect modification, and mediation by baseline physical activity was not statistically supported.</p><p><strong> Conclusion:</strong> Baseline depressive symptoms were associated with a small increase in incident osteoporosis risk among older adults. The individual?level effect size was modest, and mediation findings should be interpreted as exploratory<br />rather than causal.</p>http://jrms.mui.ac.ir/index.php/jrms/article/view/11764http://jrms.mui.ac.ir/index.php/jrms/article/download/11764/6533