In a large observational study of older men bone mineral density (BMD) was lower among the men who used SSRIs but not among those who used other antidepressants.
Their study suggests that there is an association between lower BMD and SSRI use, but there is a need for more research, because there are other potential explanations. One important next step is to also look at fracture outcomes.
"Depression is an important and a serious condition, and it's important that if people are concerned about their bones, they should talk to their doctor about their medication, but not stop their medication on their own without speaking with their physicians.... Many people will find that SSRIs are still an important and a good treatment for depression, and if that's the case, then screening and attempting prevention of bone loss can be important."
The group writes that SSRIs, which inhibit the serotonin transporter, are the first-line therapy for depression and account for approximately 62% of all antidepressants prescribed in the United States. Animal studies and data in humans show that SSRIs are associated with hip fracture. It remains unclear whether depression itself, the treatment of depression, or the effect of depression on activity, mobility, and weight change leads to decreased BMD among depressed people.
The researchers found that SSRI use was associated with lower mean BMD at the hip and spine, but there was no significant difference among users of TCAs or trazodone hydrochloride and nonusers.
The authors write that finding lower BMD among men using SSRIs is supported by in vitro and animal data. They add that "the observed effect size is similar to the well-known detrimental effect of corticosteroids on bone loss."
They caution, however, that these findings need to be confirmed in prospective studies, and that further research is needed given the widespread use of SSRIs and potentially important clinical implications. They add that if these results are confirmed, people using SSRIs might be targeted for osteoporosis screening and preventive intervention.
"The growing evidence at least supports preliminary recommendations, namely that depression and in particular SSRI use should be added to the list of risk factors that prompt clinicians to more carefully consider bone health."
"Good clinical acumen and thoughtful adverse event monitoring can help avoid having healthier minds at the expense of sicker bones."
Depression affects as many as 40% of adults older than 55 years and leads to substantial disability. Recently SSRIs surpassed first-generation TCAs and now rank third among all drug classes prescribed in the US marketplace, but a 2-fold risk for incident fracture and increased risk for falls have been demonstrated with SSRIs. According to the authors of the current study, depression itself has been associated with increased risk for hip fractures and falls, perhaps related to changes in activity, mobility, and weight, and it is unclear if the risk is related to changes in bone health related to depression, use of SSRIs, or a combination of them.
This is a cross-sectional analysis within a prospective longitudinal study of a cohort of men aged 65 years or older to compare the risk for reduced BMD associated with use and nonuse of SSRIs, TCAs, and trazodone.
Pearls for Practice
SSRI use vs nonuse among older men is associated with reduced hip and spine BMD.
TCA use, trazodone use, and nonuse of antidepressants among older men are not associated with reduced BMD at the hip and spine.
Extrait tiré de Medscape