In the Journals

Antidepressants linked to hip fracture in elderly before, after treatment initiation

In a nationwide cohort study of Swedish older adults, researchers observed a link between antidepressant use and hip fracture in the year before and year after treatment initiation.

“Antidepressant drugs are a cornerstone for the treatment of depression, but their use is associated with adverse events, especially in old age,” Jon Brännström, MD, department of community medicine and rehabilitation, geriatric medicine, Umeå University, Sweden, and colleagues wrote in JAMA Psychiatry. “A growing body of research has established associations between the use of most groups of antidepressants and hip fracture among older people.”

The investigators evaluated the connection between treatment with antidepressant medication and incident hip fracture from data collected from 1 year before to 1 year after the date of prescription being filled in a Swedish cohort of 204,072 adults aged 65 years and older. They matched these participants by birth year and sex to control for participants without an antidepressant prescription.

In addition, the researchers compared high vs. low dose users of all antidepressants and of the three most commonly prescribed antidepressants (ie, citalopram, mirtazapine and amitriptyline) separately to determine whether the link between antidepressant use and hip fracture was dose dependent.

Analysis revealed that adults taking antidepressants sustained more than twice as many hip fractures than nonusers in the year prior to (2.8% vs. 1.1%) and following (3.5% vs. 1.3%) treatment initiation. The researchers did not observe a dose-response relationship.

Brännström and colleagues found that the risk for hip fractures in antidepressant users peaked at 16 to 30 days before starting treatment (OR = 5.76; 95% CI, 4.73-7.01). When conducting separate analyses by age, sex and individual antidepressants, they also found that the highest odd ratios for the link between antidepressant use and hip fracture was 16 to 30 days prior to therapy initiation, according to the results. The patterns were similar in men and women, but the OR was higher in men.

“These findings raise questions about associations between antidepressant use and hip fracture seen in previous observational studies,” the investigators wrote. “Further analysis of this association in treatment studies and examination of the incidence of hip fracture before and after the discontinuation of treatment are required and may shed further light on the possible residual risk associated with treatment.”

Image of Donovan Maust
Donovan Maust

Rather than cease all antidepressant prescribing to this patient population, it is important for clinicians to individualize antidepressant treatment, prescribe them after carefully weighing the potential risks and benefits, and monitor patients closely, Andrea Iaboni, MD, DPhil, of department of psychiatry at University of Toronto, and Donovan T. Maust, MD, MS, of the department of psychiatry, University of Michigan, Ann Arbor, wrote in a related editorial.

“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,” Iaboni and Maust wrote. “A pragmatic preventive approach is warranted, starting with selecting the antidepressant (eg, avoiding sedating or anticholinergic agents), a cautious initial dose and dose escalation schedule, a review of potentially interacting therapies and other fall promoting medications, appropriate osteoporosis management and referral to fall prevention programs for patients with other risk factors for falls.”

Disclosures: The authors report no relevant financial disclosures. Iaboni reports personal fees from and serving as a scientific advisor for Winterlight Labs.

In a nationwide cohort study of Swedish older adults, researchers observed a link between antidepressant use and hip fracture in the year before and year after treatment initiation.

“Antidepressant drugs are a cornerstone for the treatment of depression, but their use is associated with adverse events, especially in old age,” Jon Brännström, MD, department of community medicine and rehabilitation, geriatric medicine, Umeå University, Sweden, and colleagues wrote in JAMA Psychiatry. “A growing body of research has established associations between the use of most groups of antidepressants and hip fracture among older people.”

The investigators evaluated the connection between treatment with antidepressant medication and incident hip fracture from data collected from 1 year before to 1 year after the date of prescription being filled in a Swedish cohort of 204,072 adults aged 65 years and older. They matched these participants by birth year and sex to control for participants without an antidepressant prescription.

In addition, the researchers compared high vs. low dose users of all antidepressants and of the three most commonly prescribed antidepressants (ie, citalopram, mirtazapine and amitriptyline) separately to determine whether the link between antidepressant use and hip fracture was dose dependent.

Analysis revealed that adults taking antidepressants sustained more than twice as many hip fractures than nonusers in the year prior to (2.8% vs. 1.1%) and following (3.5% vs. 1.3%) treatment initiation. The researchers did not observe a dose-response relationship.

Brännström and colleagues found that the risk for hip fractures in antidepressant users peaked at 16 to 30 days before starting treatment (OR = 5.76; 95% CI, 4.73-7.01). When conducting separate analyses by age, sex and individual antidepressants, they also found that the highest odd ratios for the link between antidepressant use and hip fracture was 16 to 30 days prior to therapy initiation, according to the results. The patterns were similar in men and women, but the OR was higher in men.

“These findings raise questions about associations between antidepressant use and hip fracture seen in previous observational studies,” the investigators wrote. “Further analysis of this association in treatment studies and examination of the incidence of hip fracture before and after the discontinuation of treatment are required and may shed further light on the possible residual risk associated with treatment.”

Image of Donovan Maust
Donovan Maust

Rather than cease all antidepressant prescribing to this patient population, it is important for clinicians to individualize antidepressant treatment, prescribe them after carefully weighing the potential risks and benefits, and monitor patients closely, Andrea Iaboni, MD, DPhil, of department of psychiatry at University of Toronto, and Donovan T. Maust, MD, MS, of the department of psychiatry, University of Michigan, Ann Arbor, wrote in a related editorial.

“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,” Iaboni and Maust wrote. “A pragmatic preventive approach is warranted, starting with selecting the antidepressant (eg, avoiding sedating or anticholinergic agents), a cautious initial dose and dose escalation schedule, a review of potentially interacting therapies and other fall promoting medications, appropriate osteoporosis management and referral to fall prevention programs for patients with other risk factors for falls.”

Disclosures: The authors report no relevant financial disclosures. Iaboni reports personal fees from and serving as a scientific advisor for Winterlight Labs.