Wednesday, January 2, 2019

Seniors With Depression May Be at Heightened Risk of Hip Fracture Before Starting Antidepressants

Despite several observational studies demonstrating that older patients taking antidepressants are at a higher risk of falls and fractures, it has remained unclear whether the use of the medication causes the increased risk. A study published today in JAMA Psychiatry suggests that older adults may be at higher risk of hip fracture even before they start taking antidepressants.

While the findings raise questions about the association between antidepressant drug use and hip fracture, study authors Jon Brännström, M.D., of Umeå University in Sweden and colleagues cautioned that doctors should continue to limit the prescription of antidepressants to older adults.

For the study, Brännström and colleagues focused on adults aged 65 years or older in Sweden who had filled a prescription for antidepressants between July 1, 2006, and December 31, 2011. The authors compared hip fracture data from one year before to one year after the date that the participant first filled the prescription for an antidepressant. Each participant was matched with one control (an adult of the same sex and age who did not use antidepressants during the study period). In total, 408,144 adults (mean age, 80.1 years) were included in the analysis.

The authors found that participants in the antidepressant group had more than twice as many incidents of hip fracture before and after the initiation of treatment than did those who did not take antidepressants. The odds ratio (OR) for the association between any antidepressant use and hip fracture peaked 16 to 30 days before the prescription was filled (OR, 5.76)—a pattern that was consistent in all separate analyses of age groups, of men and women, and of the three most commonly prescribed antidepressants (citalopram hydrobromide, mirtazapine, and amitriptyline hydrochloride), the authors noted.

“Based on our results, we suggest that older people with depression have an increased risk of hip fracture before starting antidepressant treatment, owing to a high burden of comorbidity and confounding by indication,” Brännström and colleagues wrote. “Even if antidepressant drug use does not increase the risk of hip fracture, the prescription of antidepressants to older people should be restrictive, as the evidence for positive effects is limited.”

In an accompanying editorial, Andrea Iaboni, M.D., D.Phil., of the University of Toronto and Donovan T. Maust, M.D., M.S., of the University of Michigan recommended that doctors continue to communicate the potential risks of antidepressants for older patients: “We suggest that clinicians would still be wise to inform patients about the potential risk of falling and fractures that may follow antidepressant use to allow patients to make an informed decision about treatment,” they wrote. “[F]or most older adults, the toll of untreated depression will likely outweigh the potential risks associated with antidepressant use, including falls or fractures.”

Iaboni and Maust also recommended that doctors avoid prescribing sedating or anticholinergic agents, start patients on a low dose that can be increased over time, and review other medications that patients may be taking that could increase risk of falls and fractures.

For related information, see the Psychiatric News article “Patients Taking Psychotropic Medications Found to Be at Elevated Risk of Fractures.”

(Image: iStock/Shidlovski)

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