Jan. 22, 2007 -- Elderly patients who take antidepressant drugs known as selective serotonin reuptake inhibitors, or SSRIs, may be doubling their risk of fractures from falls, a new study suggests.
The class of drugs includes the popular depression drugs Prozac and Paxil. These drugs are considered first-line therapy for treatment of depression in older adults.
And because about one in 10 elderly primary care patients in the United States suffers from depression, thousands could be affected.
The study appears in the current issue of Archives of Internal Medicine.
"What we found was that there was a twofold risk of clinical fractures in these elderly patients, and this is over and above the fact that they already had other risk factors for fractures," said study co-author Dr. David Goltzman of the department of medicine at McGill University in Montreal.
Goltzman said the fractures studied in this case were low-trauma -- so named because they occurred as a result of stress put on the bones from minor impacts or even day-to-day activities such as walking or standing up.
The findings, if accurate, may reveal how much researchers and physicians have yet to learn about this class of drugs.
"There has really not been very much research done on the effect of many drugs on bone formation, and this is true of SSRIs," said Dr. James Powers, geriatrician and associate professor at Vanderbilt University Medical Center.
"We know that SSRIs are associated with increased risk of falls, and sometimes the physician is faced with the very difficult choice of having to decide whether to treat depression and deal with the consequences of increased fall risk."
Balancing Depression Against Fracture Risk
So must elderly patients suffering from depression choose between their mental health and their hips?
Unlikely, Goltzman said.
"I wouldn't recommend that patients go off these medicines if they need them," he said. "But they should just be aware of the increased risk for fractures and take steps to minimize their chances of experiencing fractures in the future."
Powers agreed that in most cases, clinical practice for elderly depressed patients should not be changed. But he said an individual approach to each case is necessary to determine the best course of action.
"My feeling is that depression itself is a serious problem for many elderly and needs to be treated. … If … the depression symptoms are worse than the osteoporosis or history of falls and fractures, then treating their depression is a reasonable thing," he said.
"However, if a person has fallen and has had previous insufficiency fractures, then they would be at higher risk, and treatment of depression would have to take a back seat to prevention of future falls and fractures.
"Sometimes it comes down to clinical judgments when it comes to what to treat."
Physicians may also choose to use alternatives to SSRIs in certain patients who are at a particularly high risk of fractures.
"Depression can have many treatments. SSRIs are one of them, but there are other treatments as well," Powers said. "We've known for a long time that things like counseling, supportive care and music therapy are effective nonmedicine ways to deal with depression.
"Those are all still available, and they can approach the same benefits of medications."
Study May Lead to Additional Screenings, Precautions
The study may encourage physicians who treat older depression patients to think about ways to minimize the chances of fractures by lessening the effects of osteoporosis.
This could include encouraging a diet high in vitamin D and calcium, as well as safeguarding against falls in general.
"It would probably be prudent before a patient starts treatment with SSRIs that they have their bone density measured," Goltzman said. "This is especially true if the patient has already had a low-trauma clinical fracture."
Goltzman added that the study is a first step, and further research is needed before any conclusions about treatment of these patients are made. But for now, he said, physicians and patients can take precautions.
"I would hope that doctors, after reading this study, would be very aware of the probability of an increased risk of fractures in their patients when they take SSRIs," he said.