Effect of selective serotonin reuptake inhibitors on bone mineral density: a systematic review and meta-analysis

Plasma serotonin precursors and metabolite are correlated with bone mineral density and bone turnover markers in patients with postmenopausal osteoporosis

BACKGROUND

Serotonin (5-HT) precursors regulate bone remodeling. This study aims to investigate the correlation of plasma 5-HT precursors and metabolite with bone mineral density (BMD) and bone turnover markers in postmenopausal osteoporosis (PMOP) patients.

METHODS

The age, body mass index (BMI), and years since menopause (YSM) were documented for 348 postmenopausal women in normal/osteopenia/osteoporosis (OP) groups, with lumbar spine and femoral neck BMD measured. Serum bone turnover markers (PINP/β-CTX) and plasma 5-HT, 5-HT precursors (Trp/5-HTP) and metabolite (5-HIAA) were measured by ELISA. OP patients were allocated to high/low expression groups following ROC analysis of 5-HT/Trp/5-HTP/5-HIAA. The relationship of plasma 5-HT/Trp/5-HTP/5-HIAA, BMD, and bone turnover markers with PMOP was analyzed using logistic regression analysis. The correlation of plasma 5-HT/Trp/5-HTP/5-HIAA with BMD and bone turnover markers was analyzed using Pearson's correlation analysis, followed by logistic regression analysis of the relationship between plasma 5-HT/Trp/5-HTP/5-HIAA and BMD, bone turnover markers and PMOP.

RESULTS

BMI, YSM, BMD and PINP, and β-CTX levels differed among groups. Levels of plasma 5-HT precursors/metabolite were increased in OP patients. Individuals with high 5-HT precursors/metabolite levels had low BMD and high PINP/β-CTX levels. The 5-HT precursors/metabolite negatively-correlated with BMD and positively-correlated with PINP/β-CTX. BMI, YSM, BMD, and PINP/β-CTX/Trp/5-HTP/5-HT related to PMOP and were independent risk factors for OP.

CONCLUSION

Plasma 5-HT precursors and metabolite negatively-correlate with BMD and positively-correlate with PINP/β-CTX in PMOP patients. Peripheral 5-HT precursors and metabolite level may be a new direction of treatment of PMOP and bone metabolism-related disorders.

Link between depression and bone mineral density in Cooper Center Longitudinal Study: Indirect effects of vitamin D, inflammation, and physical activity

BACKGROUND

To examine the effect of depressive symptom severity on bone mineral density (BMD) and the potential mediators of the relationship.

METHOD

This study used data from n = 7273 participants in the Cooper Center Longitudinal Study at the Cooper Clinic in Dallas. Participants were included if they had data for all study variables, including left and right femoral neck (BMD), age, sex, body mass index, smoking status, antidepressant (SSRI/SNRI) use, standard alcoholic drinks consumed per week, and depressive symptom severity as measured with the Center for Epidemiological Studies-Depression (CESD)-10. To evaluate the effect of depressive symptoms on both L/R femur BMD, two multiple linear regression analyses were conducted. To examine effects of vitamin D, high sensitivity C-reactive protein (hs-CRP), and physical activity (MET units) on the relationship between depressive symptom severity and BMD, parallel mediation analyses were conducted.

RESULTS

Depressive symptom severity (CES-D 10 score) significantly predicted both L/R BMD (L: β = -0.048, R: β = -0.047, both p ≤ .001). Only physical activity significantly mediated the relationship between depressive symptom severity and L/R BMD (L: β = -0.008, 95 % CI [-0.011, -0.005]; R: β = -0.007, 95 % CI [-0.010, -0.005]).

LIMITATIONS

The sample may not be generalizable to all patient populations.

CONCLUSION

Depressive symptom severity was inversely related to both L/R femur BMD in a large cohort of relatively healthy adults. Physical activity, but not vitamin D or hs-CRP, mediated this relationship. Future research might examine the effect of physical activity interventions both on depression and BMD.

IMPACT STATEMENT

We certify that this work is both novel and confirmatory of recent clinical research (Lee et al., 2015; Amsterdam and Hooper, 1998; Hlis et al., 2018; Wainstein et al., 2016; Blair et al., 1989; Farrell et al., 2022; Ainsworth et al., 2011). We demonstrated a negative relationship between depression and BMD in a large cohort of adults and expanded on previous findings by demonstrating that physical activity acts as a mediator of this relationship. Physical activity is known to stimulate osteogenesis in osteoporotic patients, and this study further expands on its role in depressive symptoms in this population.

KEY POINTS

An Update on Drug-Nutrient Interactions and Dental Decay in Older Adults

In recent decades, the global demographic landscape has undergone a discernible shift that has been characterised by a progressive increase in the proportion of elderly individuals, indicative of an enduring global inclination toward extended lifespans. The aging process, accompanied by physiological changes and dietary patterns, contributes to detrimental deviations in micronutrient consumption. This vulnerable aging population faces heightened risks, including dental caries, due to structural and functional modifications resulting from insufficient nutritional sustenance. Factors such as physiological changes, inadequate nutrition, and the prevalence of multiple chronic pathologies leading to polypharmacy contribute to the challenge of maintaining an optimal nutritional status. This scenario increases the likelihood of drug interactions, both between medications and with nutrients and the microbiome, triggering complications such as dental decay and other pathologies. Since the drug industry is evolving and new types of food, supplements, and nutrients are being designed, there is a need for further research on the mechanisms by which drugs interfere with certain nutrients that affect homeostasis, exemplified by the prevalence of caries in the mouths of older adults. Infectious diseases, among them dental caries, exert serious impacts on the health and overall quality of life of the elderly demographic. This comprehensive review endeavours to elucidate the intricate interplay among drugs, nutrients, the microbiome, and the oral cavity environment, with the overarching objective of mitigating the potential hazards posed to both the general health and dental well-being of older adults. By scrutinising and optimising these multifaceted interactions, this examination aims to proactively minimise the susceptibility of the elderly population to a spectrum of health-related issues and the consequences associated with dental decay.

The application of CGF combined with GBR in alveolar bone increment for patients with anxiety disorder: A rare case report and literature review

RATIONALE

Selective serotonin reuptake inhibitors (SSRIs), one of the commonly used anti-anxiety drugs, may have impacts on bone metabolism and potentially lead to drug-induced osteoporosis. The traditional approach of oral implantation in individuals with both anxiety disorder and drug-induced osteoporosis poses a significant challenge. To address this issue, concentrated growth factor (CGF) has been utilized in patients undergoing concurrent alveolar ridge augmentation during oral implantation, resulting in favorable clinical outcomes. Consequently, combining CGF with guided bone regeneration (GBR) in alveolar bone increment may represent a promising new surgical approach for such patients. In this report, we present a case study of a 25-year-old male with anxiety disorder and drug-induced osteoporosis, in who CGF combined with GBR was employed in alveolar bone increment.

PATIENT CONCERNS

This article reports the case of a 25-year-old male who underwent cone beam computed tomography (CBCT) due to the absence of his right lower second molar for a period of six months. The CBCT scan revealed significant bone defects, which were attributed to the tooth loss and prolonged use of anti-anxiety drugs. Consequently, the patient sought medical assistance from our department.

DIAGNOSES

Based on the patient's self-report, he was diagnosed with an anxiety disorder. Additionally, the CBCT scan confirmed the loss of the right mandibular second molar and revealed the presence of dental irregularity and an alveolar bone defect.

INTERVENTIONS

During the patient's course of treatment with anti-anxiety medication, a combination of CGF and GBR was employed for the simultaneous implantation of the missing right mandibular second molar, along with bone augmentation.

OUTCOMES

The patient had a follow-up visit two weeks after the surgical procedure, and the wound in the operation area had healed satisfactorily. Six months later, CBCT images revealed excellent osseointegration. The buccal and lingual width of the alveolar bone measured 6.95mm, which was an increase of 1.35mm compared to the pre-implantation stage.

LESSONS

This article presents a case study in which CGF combined with GBR were utilized to address alveolar bone augmentation during the implantation phase in patients taking anti-anxiety medication. The results demonstrated that CGF combined with GBR, as a cutting-edge platelet concentrate technique, could effectively stimulate bone tissue proliferation in individuals who have been on long-term anti-anxiety medication, specifically in oral implant areas. This approach can help prevent poor osseointegration, promote higher osseointegration rates, and facilitate wound healing.

Effect of Selective Serotonin Reuptake Inhibitor (Paroxetine) on Newly Formed Bone Volume: Real-Time In Vivo Micro-computed Tomographic Analysis

INTRODUCTION

Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat depression and anxiety. The purpose of this study was to assess in real time the effect of paroxetine, an SSRI, on newly formed bone volume (NFBV) in standardized calvarial defects (SCDs) in rats.

METHODS

Fourteen Wistar albino female rats with a mean age of 7.5 months and a mean weight of 275 g were used. The animals were randomly divided into 2 groups. The experimental group was given paroxetine 8 weeks before the surgical procedure and throughout the experiment, and the control group was given a placebo 8 weeks before the surgical procedure and throughout the experiment. In each group, 14 SCDs measuring 4.6 mm in diameter were created on the parietal bone. In both groups, a Bio-Oss + collagen membrane was placed. All defects showed primary closure. The volume of the newly formed bone (NFBV) was measured using in vivo micro-computed tomographic imaging. Measurements were taken at days 0, 14, 28, 42, and 56 after surgery using real-time assessment with micro-computed tomographic imaging.

RESULTS

The mean NFBV was 17.12 ± 4.52 mm3 and 12.52 ± 4.78 mm3 for the control and experimental groups, respectively, at day 56. The differences between the 2 groups were statistically significant (P < .05) at all time intervals.

CONCLUSIONS

Paroxetine intake significantly reduced the amount of regenerated NFBV and the rate of new bone formation.

Selective Serotonin Reuptake Inhibitors and Other Treatment Modalities for Deep Space Missions

INTRODUCTION: As humankind ventures further into the depths of space, planning is already underway for long-duration exploration missions that will test the bounds of human performance. Deep space travel will include added risk related to stressors from the isolated, confined, and extreme environment that lies outside the boundaries of low Earth orbit. Currently, selective serotonin reuptake inhibitors (SSRIs) are considered the standard of care for many mental health diagnoses, including anxiety and depression; however, SSRIs are also associated with several undesired side effects. The utility of nonpharmacological therapies for the management of behavioral health conditions has not yet been fully explored.METHODS: A comprehensive literature search was performed using PubMed. Relevant articles pertaining to the psychological impacts of isolated, confined, and extreme environments, use of SSRIs in spaceflight, side effects associated with SSRIs, and nonpharmacological treatments for anxiety and depression were reviewed. Over 70 studies were reviewed in total.RESULTS: Reduced bone mineral density, impaired hemostatic function, significant individual variability resulting from gene polymorphisms, and drug-drug interactions are well described adverse effects of SSRIs that may complicate their operational use in the deep space environment. Four alternative therapies for the treatment of anxiety and depression may show promise for long duration missions.DISCUSSION: Although SSRIs have long been considered standard of care treatment for many behavioral health conditions, we cannot trivialize the risk that prolonged pharmacological therapy may pose. The need to mitigate these risks by exploring alternative therapies has never been more relevant.El-Khoury BB, Ray KL, Altchuler SI, Reichard JF, Dukes CH. Selective serotonin reuptake inhibitors and other treatment modalities for deep space missions. Aerosp Med Hum Perform. 2023; 94(11):843-851.

Comorbidity between major depressive disorder and physical diseases: a comprehensive review of epidemiology, mechanisms and management

Populations with common physical diseases - such as cardiovascular diseases, cancer and neurodegenerative disorders - experience substantially higher rates of major depressive disorder (MDD) than the general population. On the other hand, people living with MDD have a greater risk for many physical diseases. This high level of comorbidity is associated with worse outcomes, reduced adherence to treatment, increased mortality, and greater health care utilization and costs. Comorbidity can also result in a range of clinical challenges, such as a more complicated therapeutic alliance, issues pertaining to adaptive health behaviors, drug-drug interactions and adverse events induced by medications used for physical and mental disorders. Potential explanations for the high prevalence of the above comorbidity involve shared genetic and biological pathways. These latter include inflammation, the gut microbiome, mitochondrial function and energy metabolism, hypothalamic-pituitary-adrenal axis dysregulation, and brain structure and function. Furthermore, MDD and physical diseases have in common several antecedents related to social factors (e.g., socioeconomic status), lifestyle variables (e.g., physical activity, diet, sleep), and stressful live events (e.g., childhood trauma). Pharmacotherapies and psychotherapies are effective treatments for comorbid MDD, and the introduction of lifestyle interventions as well as collaborative care models and digital technologies provide promising strategies for improving management. This paper aims to provide a detailed overview of the epidemiology of the comorbidity of MDD and specific physical diseases, including prevalence and bidirectional risk; of shared biological pathways potentially implicated in the pathogenesis of MDD and common physical diseases; of socio-environmental factors that serve as both shared risk and protective factors; and of management of MDD and physical diseases, including prevention and treatment. We conclude with future directions and emerging research related to optimal care of people with comorbid MDD and physical diseases.

Examining Whether Genetic Variants Moderate the Skeletal Effects of Selective Serotonin Reuptake Inhibitors in Older Adolescents and Young Adults

Objective: To examine whether serotonin (5-HT) related genetic variants moderate the effects of selective serotonin reuptake inhibitors (SSRIs) on skeletal outcomes. Methods: Trabecular bone mineral density (BMD) at the radius, lumbar spine (LS) BMD, total body less head (TBLH) bone mineral content (BMC) and markers of bone metabolism (osteocalcin, C-terminal telopeptide of type I collagen [CTX-1], and bone specific alkaline phosphatase to CTX-1 ratio) were examined in an observational study, enrolling 15- to 20-year-old participants, unmedicated or within a month of SSRI initiation. Variants in HTR1A (rs6295), HTR1B (rs6296), HTR1D (rs6300), HTR2A (rs6311 and rs6314), HTR2B (rs6736017), and the serotonin transporter intron 2 variable number tandem repeat (STin2 VNTR) were genotyped. Linear mixed-effects regression analysis examined associations between SSRI use, genetic variants, and skeletal outcomes. Results: After adjusting for relevant covariates, rs6295 CC and GC genotypes in 262 participants (60% female, mean ± SD age = 18.9 ± 1.6 years) were significantly associated with higher LS BMD compared to the GG genotype. Rs6311 GG SSRI users had greater LS BMD compared to nonusers (β = 0.18, p = <0.0001). Female SSRI users with the combination of rs6295 CC+GC and rs6311 GG genotypes had greater LS BMD than female SSRI nonusers (β = 0.29, p < 0.0001). SSRI users with the rs6295 GG genotype had higher trabecular BMD compared to nonusers (β = 3.60, p = 0.05). No significant interactions were found for TBLH BMC or bone turnover markers. After correcting for multiple comparisons, none of the results retained significance. Conclusions: In older adolescents and young adults, HTR1A (rs6295) and HTR2A (rs6311) variants may moderate the effect of SSRIs on BMD. Sex differences may exist and require further examination. Further research with larger sample sizes is needed to confirm our preliminary findings. Clinical Trial Registration: clinicaltrials.gov NCT02147184.

The use of antidepressants is linked to bone loss: A systematic review and metanalysis

INTRODUCTION

Depression and antidepressants are among risk factors for osteoporosis. However, there are still inconsistencies in literature regarding bone consequences of antidepressant drugs and the role of age and the natural decline of bone health in patients with depression.

OBJECTIVE

To investigate the relationship between antidepressant and bone mineral density (BMD).

METHODS

We conducted a systematic review and metanalysis according to PRISMA guidelines searching on PubMed/Medline, Cochrane Database, and Scopus libraries and registered with PROSPERO (registration number CRD42021254006) using generic terms for antidepressants and BMD. Search was restricted to English language only and without time restriction from inception up to June 2021. Methodological quality was assessed with the Newcastle-Ottawa scale.

RESULTS

Eighteen papers were included in the qualitative analysis and five in the quantitative analysis. A total of 42,656 participants affected by different subtypes of depression were identified. Among the included studies, 10 used serotonin reuptake inhibitors (SSRIs) only, 6 involved the use of SSRIs and tricyclic antidepressants, and 2 the combined use of more than two antidepressants. No significant studies meeting the inclusion criteria for other most recent categories of antidepressants, such as vortioxetine and esketamine. Overall, we observed a significant effect of SSRI on decrease of BMD with a mean effect of 0.28 (95% CI = 0.08, 0.39).

CONCLUSION

Our data suggest that SSRIs are associated with a decrease of BMD. We aim to raise clinicians' awareness of the potential association between the use of antidepressants and bone fragility to increase monitoring of bone health.

Antidepressants and Vertebral and Hip Risk Fracture: An Updated Systematic Review and Meta-Analysis

Although antidepressant drugs appear to play an active role in increasing fracture risk, their weight is still unclear. We conducted a PRISMA compliant systematic review and meta-analysis through PubMed/Scopus/Cochrane libraries and registered with PROSPERO (registration number CRD42021254006) to investigate the relationship between antidepressant drugs categories, including SSRIs, SNRIs, and TCAs, and the risk of hip and vertebral fractures. After screening 3122 items, we finally found 26 papers for qualitative analysis and 11 for quantitative synthesis. A total of 15,209,542 adult and elderly patients were identified, with a mean follow-up of 51 months and a major prevalence of women. We identified results largely for SSRIs, with only a small amount of data for SNRIs, TCAs, and NaSSA. No data were found among the most recent categories of antidepressants, such as vortioxetine and esketamine. All included studies reported hip fractures, while three of them also included vertebral fractures. Overall, we observed a significant effect of SSRIs on fracture risk with a mean effect of 0.98 (95% CI = 0.75–1.20). This meta-analysis reveals that the use of SSRIs increases the risk of fractures. Clinicians’ awareness in antidepressant prescription should optimize their potential while reducing this risk.

Bone Mineral Density Measurements and Association With Brain Structure and Cognitive Function: The Framingham Offspring Cohort

BACKGROUND

Bone mineral density (BMD) is a potential surrogate marker of lifetime estrogen exposure previously linked to increased risk of Alzheimer dementia among elderly women. We examine the association between BMD in the "young old" with imaging biomarkers of brain aging and cognitive performance.

METHODS

Offspring participants (N=1905, mean age 66) of a population-based cohort who had BMD, brain imaging and detailed cognitive assessment were included in the study. Sex-stratified, linear, and logistic regression models were used for analysis.

RESULTS

Higher femoral neck BMD was associated with lower white matter hyperintensity burden and better performance on Trails B-A in both sexes, even after adjustment for cerebrovascular risk factors. Among women, the positive association with Trails B-A performance was seen only in APOE4 allele carriers. Higher BMD measurements were linked to better visual reproductions test performance in men. Finally, among women, higher femoral trochanter BMD was associated with better logical memory and Hooper visual organization test performance.

CONCLUSION

Among the "young old," higher BMD is associated with less white matter hyperintensity burden and better, domain-specific, cognitive performance. This suggests that lifetime estrogen exposure may modulate the degree of cumulative vascular brain injury independent of cerebrovascular risk factors.

Use of serotonin reuptake inhibitors and risk of subsequent bone loss in a nationwide population-based cohort study

This study examined whether the use of SRIs is associated with an increased risk of bone loss using a nested case-control design with a nationwide population-based cohort in Korea. Using the Korean National Health Screening Cohort, subjects newly diagnosed with osteoporosis or osteopenia (n = 55,799) were matched with controls (n = 278,995) at a ratio of 1:5. We stratified the participants by their time-dependent use of SRIs and sex and controlled for various confounders, including lifestyle habits, laboratory data, and comorbidities. Conditional logistic regression showed that both recent and former users of SRIs had an increased risk of subsequent bone loss compared with non-users: men [recent users: odds ratio (OR) 1.35, 95% confidential interval (CI) 1.20, 1.53; former-users: OR 1.10, 95% CI 1.01, 1.20]; women (recent users: OR 1.38, 95% CI 1.28-1.48; former-users: OR 1.07, 95% CI 1.02, 1.21). The use of SRIs was associated with an increased risk of bone loss in both men and women. In particular, the association was stronger in recent users. These findings provide population-level evidence for the risk of bone loss associated with SRI exposure and highlight the importance of monitoring the bone health of SRI users.

The prevention of osteoporosis and sarcopenia in older adults

Osteoporosis and sarcopenia are common in older adults. Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Bone fractures can result in changes in posture, pain, the need for surgical repair and functional impairment. Sarcopenia is the progressive and generalized loss of skeletal muscle mass, strength and/or physical performance. Older adults with sarcopenia experience increased risk of frailty, disability, hospitalizations, mortality, and a reduced quality of life. In this narrative review we provide guidance regarding the prevention of both osteoporosis and sarcopenia, including interventions that prevent both conditions from occurring, recommended screening and treatment to prevent progression.

Serotonin 2A (5-HT2A) receptor affects cell-matrix adhesion and the formation and maintenance of stress fibers in HEK293 cells

5-HT_2A, a G-protein coupled receptor, is widely expressed in the human body, including in the gastrointestinal tract, platelets and the nervous system. It mediates various functions, for e.g. learning, memory, mood regulation, platelet aggregation and vasoconstriction, but its involvement in cell-adhesion remains largely unknown. Here we report a novel role for 5-HT_2A in cell–matrix adhesion.

In HEK293 cells, which are loosely adherent, expression and stimulation of human or rat 5-HT_2A receptor by agonists such as serotonin or 2,5-dimethoxy-4-iodoamphetamine (DOI) led to a significant increase in adhesion, while inhibition of 5-HT_2A by antipsychotics, such as risperidone, olanzapine or chlorpromazine prevented it. 5-HT_2A activation gave rise to stress fibers in these cells and was also required for their maintenance. Mechanistically, the 5-HT_2A-mediated adhesion was mediated by downstream PKC and Rho signaling. Since 5-HT_2A is associated with many disorders such as dementia, depression and schizophrenia, its role in cell–matrix adhesion could have implications for neural circuits.

Current anti-depressant use is associated with cortical bone deficits and reduced physical function in elderly women

BACKGROUND

Anti-depressants, particularly selective serotonin reuptake inhibitors (SSRIs), are associated with an increased risk of fracture. The mechanism is unclear and may be due to effects on bone metabolism, muscle strength, falls or other factors. It is unknown if serotonin norepinephrine reuptake inhibitors (SNRIs) have similar effects.

METHODS

We compared musculoskeletal health in current female anti-depressant users and non-users from a population-based multiethnic (35.6% black, 22.3% white and 42.1% mixed) cohort study of adults ≥65 years old in New York (N = 195) using dual x-ray absorptiometry (DXA), trabecular bone score (TBS), vertebral fracture assessment (VFA), high resolution peripheral quantitative computed tomography (HR-pQCT), body composition, and grip strength.

RESULTS

Current anti-depressant users were more likely to be white than non-white (OR 1.9, 95% CI 1.2-2.9) and were shorter than non-users, but there were no differences in age, weight, BMI, physical activity, calcium/vitamin D intake, falls or self-rated health. There were more pelvic fractures in current vs. non-users (7.1% vs. 0%, p = 0.04). Age- and weight-adjusted T-score by DXA was lower in current users at the 1/3-radius (-1.6 ± 1.1 vs. -1.0 ± 1.4, p = 0.04) site only. There was no difference in TBS, vertebral fractures or fat/lean mass by DXA. Age- and weight-adjusted grip strength was 13.3% lower in current users vs. non-users (p = 0.04). By HR-pQCT, age- and weight-adjusted cortical volumetric BMD (Ct. vBMD) was 4.8% lower in users vs. non-users at the 4% radius site (p = 0.007). A similar cortical pattern was seen at the proximal (30%) tibia. When assessed by anti-depressant class, deteriorated cortical microstructure was present only in SSRI users at the radius and only in SNRI users at the proximal tibia.

CONCLUSIONS

Anti-depressant use is associated with cortical deterioration and reduced physical function, but effects may be class-specific. These findings provide insight into the mechanism by which anti-depressants may contribute to the increased fracture risk in older women.

Alliance between selective serotonin reuptake inhibitors and fracture risk: an updated systematic review and meta-analysis

PURPOSE

In the past few years, several fracture-related events have been reported with chronic use of selective serotonin reuptake inhibitors (SSRIs) throughout the globe. Hence, an updated systematic review and meta-analysis was necessary to ascertain the risk involved. The present work evaluated the association of SSRIs with the risk of fracture in adults.

METHODS

We systematically searched PubMed, Cochrane library, and Google Scholar for observational studies on the same from inception to April 2019. Screening, data extraction, and risk of bias assessment were conducted independently by 2 authors.

RESULTS

We assessed 69 studies out of which 37 (14 case-control, 23 cohorts) were included. Our results showed that SSRIs were significantly associated with an increased fracture risk (relative risk of 1.62, 95% CI 1.52-1.73; P < 0.000; I² = 90.8%). The relative risk values for case-control and cohort studies were found to be 1.80 (95% CI 1.58-2.03; P < 0.000; I² = 93.2%) and 1.51 (95% CI 1.39-1.64; P < 0.000; I² = 88.0%) respectively. Subgroup analysis showed that association of risk of fracture persisted regardless of geographical location, study design, risk factors, defined daily dose, SSRI use duration, site of the fracture, period of study and after adjusting for depression, physical activity, gender, and age group. The sensitivity analysis data shows that the studies adjusted for bone mineral density and osteoporosis show lesser fracture risk.

CONCLUSION

Our findings suggests that SSRIs may be associated with an increased fracture risk; hence, bone health should be taken into consideration while prescribing this class of drugs.

The Skeletal-Protecting Action and Mechanisms of Action for Mood-Stabilizing Drug Lithium Chloride: Current Evidence and Future Potential Research Areas

Lithium, the lightest natural-occurring alkali metal with an atomic number of three, stabilizes the mood to prevent episodes of acute manic and depression. Multiple lines of evidence point to lithium as an anti-suicidal, anti-viral, anti-cancer, immunomodulatory, neuroprotective and osteoprotective agent. This review article provides a comprehensive review of studies investigating the bone-enhancing effects of lithium and its possible underlying molecular mechanisms. Most of the animal experimental studies reported the beneficial effects of lithium in defective bones but not in healthy bones. In humans, the effects of lithium on bones remain heterogeneous. Mechanistically, lithium promotes osteoblastic activities by activating canonical Wingless (Wnt)/beta (β)-catenin, phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt) and bone morphogenetic protein-2 (BMP-2) transduction pathways but suppresses osteoclastic activities by inhibiting the receptor activator of nuclear factor-kappa B (RANK)/receptor activator of nuclear factor-kappa B ligand (RANKL)/osteoprotegerin (OPG) system, nuclear factor-kappa B (NF-κB), mitogen-activated protein kinase (MAPK), and calcium signaling cascades. In conclusion, lithium confers protection to the skeleton but its clinical utility awaits further validation from human clinical trials.

Psychotropic medications and proton pump inhibitors and the risk of fractures in the teriparatide versus risedronate VERO clinical trial

BACKGROUND

VERO is a fracture endpoint study in women with established osteoporosis that showed reduction in the risks of new vertebral fractures (VFx) and clinical fractures in women randomized to teriparatide compared with risedronate. Patients on psychotropic drugs (hypnotics, benzodiazepines and antidepressants [selective serotonin- and norepinephrine-reuptake inhibitors: SSRIs and SNRIs]) and proton pump inhibitors (PPIs) may be at a higher risk of fractures. We studied the association of exposure to these medications with the risk of fractures in the VERO study cohort, including an assessment of their potential interactions with the assigned clinical trial drugs.

METHODS

A total of 1360 postmenopausal women with at least 2 moderate or 1 severe VFx and bone mineral density T-score ≤-1.50 were randomized to subcutaneous daily teriparatide (20μg) or oral weekly risedronate (35mg) in a double-blind, double-dummy, 2-year trial. In thispost-hoc analysis, multivariable log-binomial and Cox proportional hazards regression models were used to estimate adjusted risk ratios (RR) or hazard ratios (HR) for the exposure to these concomitant medications with the occurrence of incident fractures. We also assessed treatment effect modifications on anti-fracture efficacy driven by the use of these medications.

RESULTS

There were 406 (29.9 %), 347 (25.5 %) and 176 (12.9 %) subjects taking PPIs, benzodiazepines/hypnotics, and SSRIs/SNRIs during the study, respectively. For all fracture endpoints, the greater risk reduction of teriparatide versus risedronate did not significantly differ within the categories of psychotropic drugs and PPIs. Multivariable analysis showed that the risk of pooled new and worsened VFx was higher in PPI users than in non-PPI users (RR: 1.57; p=0.032), regardless of the study treatment. Benzodiazepine/hypnotic drug users showed an increased risk of clinical fractures (HR: 1.71; p=0.026) and non-vertebral fragility fractures (NVFFx, HR: 1.89; p=0.017), regardless of the study treatment. Increases in the risk of clinical fractures (HR: 1.93; p=0.018) and NVFFx (HR: 2.16; p=0.011) were also observed in SSRI/SNRI users, regardless of the study treatment.

CONCLUSION

In postmenopausal women with severe osteoporosis, the superior anti-fracture efficacy of teriparatide compared with risedronate was consistent regardless of psychotropic or PPI drugs use. Patients taking psychotropic drugs and PPIs showed a higher risk for NVFFx and VFx respectively, compared to those not on these medications.

Proceedings of the 2019 Santa Fe Bone Symposium: New Concepts in the Care of Osteoporosis and Rare Bone Diseases

The 20th annual Santa Fe Bone Symposium was held August 9-10, 2019, in Santa Fe, New Mexico, USA. This is an annual meeting devoted to clinical applications of recent advances in skeletal research that impact the care of patients with osteoporosis, metabolic bone diseases, and inherited bone diseases. Participants included practicing and academic physicians, fellows, advanced practice providers, fracture liaison service (FLS) coordinators, clinical researchers, and bone density technologists. The symposium consisted of lectures, case presentations, and panel discussions, with an emphasis on learning through interaction of all attendees. Topics included new approaches in the use of anabolic agents for the treatment osteoporosis, a review of important events in skeletal health over the past year, new and emerging treatments for rare bone diseases, the use of genetic testing for bone diseases in clinical practice, medication-associated causes of osteoporosis, new concepts in the use of estrogen therapy for osteoporosis, new Official Positions of the International Society for Clinical Densitometry, skeletal consequences of bariatric surgery, and update on the progress and potential of Bone Health TeleECHO, a virtual community of practice using videoconferencing technology to link healthcare professionals for advancing the care of osteoporosis worldwide. Sessions on rare bone diseases were developed in collaboration with the Rare Bone Disease Alliance. Symposium premeetings included an FLS workshop by the National Osteoporosis Foundation and others devoted to the use of new therapeutic agents for the care of osteoporosis and related disorders.

Effects of antidepressants with different modes of action on early life stages of fish and amphibians

Drugs are excreted from the human body as both original substances and as metabolites and enter aquatic environment through waste water. The aim of this study was to widen the current knowledge considering the effects of waterborne antidepressants with different modes of action-amitriptyline, venlafaxine, sertraline-on embryos of non-target aquatic biota-fish (represented by Danio rerio) and amphibians (represented by Xenopus tropicalis). The tested concentrations were 0.3; 3; 30; 300 and 3000 μg/L in case of amitriptyline and venlafaxine and 0.1; 1; 10; 100 and 1000 μg/L for sertraline. Test on zebrafish embryos was carried out until 144 h post fertilization, while test on Xenopus embryos was terminated after 48 h. Lethal and sublethal effects as well as swimming alterations were observed at higher tested concentrations that are not present in the environment. In contrast, mRNA expression of genes related to heart, eye, brain and bone development (nkx2.5, otx 2, bmp4 and pax 6) seems to be impacted also at environmentally relevant concentrations. In a wider context, this study reveals several indications on the ability of antidepressants to affect non target animals occupying environments which may be contaminated by such compounds.

Physiological Measurements for Prescribing Psychotropic Medications

Prescribing for individuals with mental health problems requires a thorough initial assessment that includes extensive interviewing of the client and significant others, review of medical records, and physical appraisals, such as vital signs, laboratory tests, and electrocardiography. Arriving at a diagnosis and treatment plan includes ruling out comorbid conditions as well as medical conditions that mimic psychiatric disorders. Because substance use frequently coincides with other psychiatric disorders and has serious health consequences, this potential for misuse of substances must also be considered. The current article focuses on the physiological assessments necessary for prescribing and monitoring psychotropic medications. [Journal of Psychosocial Nursing and Mental Health Services, 57(8), 7-10.].

Effect of selective serotonin reuptake inhibitors on markers of bone loss

Several preclinical and clinical studies show that selective serotonin reuptake inhibitors (SSRI's) are associated with bone loss and an increase in fracture risk, not many reports on their effect on bone turnover markers. This cross-sectional study evaluated the effect of SSRIs treatment on bone turnover markers in Indian population for the first time. Inclusion criteria were subjects of either sex and age 18-45 years undergoing treatment with an SSRI for at least 3 months, regardless of the indication. The results were compared with age-matched healthy controls. A total of 141 subjects were screened out of which 85 were enrolled, 44 in treatment and 41 in the control group. Serum Procollagen Type 1 Amino Terminal Propeptide (P1NP) levels were decreased in patients on SSRI treatment whereas no change was observed in the beta-C-terminal telopeptide (β-CTX) and receptor activator of nuclear factor kappa-Β ligand (RANKL) levels suggesting that these drugs can reduce bone formation but not resorption. Patients on SSRI treatment also showed reduced pCREB levels indicating that reduced bone formation is possibly through the gut mediated pathway. Our study suggests that SSRIs treatment at therapeutic doses may have a deteriorating effect on bone requiring caution in patients with additional risk factors.

Selective serotonin reuptake inhibitor use in hip fracture patients: a Danish nationwide prevalence study

Background and purpose - Selective serotonin reuptake inhibitors (SSRIs) are often used in the elderly and are associated with adverse effects. Therefore, it is important to ascertain the prevalence of SSRI use in fragile and surgery-treated hip fracture patients. Methods - This population-based prevalence study included Danish hip fracture patients aged ≥ 65 years operated in 2006-2016 (n = 68,607) and matched individuals from the background population (n = 343,020). Using Poisson regression, prevalence risk ratios (PRRs) with 95% confidence intervals (CIs) were estimated to compare hip fracture patients with the general population, and to estimate the association between hip fracture patient characteristics and SSRI prescriptions. Results - The prevalence of SSRI use among hip fracture patients was 23% compared with 12% in the general population. During 2006-2016, the prevalence decreased from 26% to 18% among hip fracture patients and from 13% to 10% in the general population. Factors associated with SSRI use in hip fracture patients were age 75-84 years (PRR 1.18, CI 1.13-1.23), age ≥ 85 years (PRR 1.17, CI 1.11-1.22), female sex (PRR 1.13, CI 1.09-1.17), unmarried status (PRR 1.15, CI 1.11-1.19), living in a residential institution (PRR 2.30, CI 2.19-2.40), Charlson comorbidity index (CCI) score 1-2 (PRR 1.50, CI 1.45-1.55), CCI score 3+ (PRR 1.62, CI 1.55-1.69), and several medications. Interpretation - The prevalence of SSRI use was high among hip fracture patients compared with the general population. Our data stress the importance of continued clinical awareness of frailty, comorbidity, and polypharmacy of hip fracture patients and the potentially adverse drug effects of SSRI treatment.

VITamin D and OmegA-3 TriaL (VITAL) bone health ancillary study: clinical factors associated with trabecular bone score in women and men

We investigated the association of clinical variables with TBS at baseline in the bone health sub-cohort of the VITamin D and OmegA-3 TriaL (VITAL). Lower TBS was associated with female sex, aging, BMI ≥ 25 kg/m², SSRI use, high alcohol intake, and presence of diabetes; there was a trend towards significance between lower TBS and history of fragility fractures.

INTRODUCTION

We investigated whether TBS differs by sex, race, body mass index (BMI), and other clinical variables.

METHODS

The VITamin D and OmegA-3 TriaL (VITAL) is determining effects of vitamin D₃ and/or omega-3 fatty acid (FA) supplements in reducing risks of cancer and cardiovascular disease. In the VITAL: Effects on Bone Structure/Architecture ancillary study, effects of these interventions on bone will be investigated. Here, we examine the associations of clinical risk factors with TBS assessments at baseline in the bone health sub-cohort, comprised of 672 participants (369 men and 303 women), mean (± SD) age 63.5 ± 6.0 years; BMI ≤ 37 kg/m², no bisphosphonates within 2 years or other bone active medications within 1 year.

RESULTS

TBS was greater in men than women (1.311 vs. 1.278, P < 0.001) and lower with elevated BMIs (P < 0.001), higher age (P = 0.004), diabetes (P = 0.008), SSRI use (P = 0.044), and high alcohol intake (P = 0.009). There was a trend for history of fragility fractures (P = 0.072), and lower TBS. TBS did not vary when analyzed by race, smoking, history of falls, and multivitamin or caffeine use.

CONCLUSIONS

Lower TBS was associated with female sex, aging, BMI ≥ 25 kg/m², SSRI use, alcohol use, and presence of diabetes; there was a trend between lower TBS and history of fragility fractures. TBS may be useful clinically to assess structural changes that may be associated with fractures among patients who are overweight or obese, those on SSRIs, or with diabetes. Ongoing follow-up studies will clarify the effects of supplemental vitamin D₃ and/or FA's on TBS and other bone health measures.

TRIAL REGISTRATION

NCT01747447.

Management of Late-Life Depression

Depression is a common disorder in late life that is associated with poor quality of life, increased disability, and increased all-cause mortality. Rates of completed suicide are the highest in older depressed men compared with any other age group. In this age group, depression is often concurrent with medical illness and it can aggravate the course of medical illness. Cognitive impairment is frequently present and may be the result of the depression itself or may be the consequence of a neurodegenerative disorder such as Alzheimer's disease. Evidence-based psychotherapies, antidepressants, and somatic treatments such as electroconvulsive therapy are employed in the treatment of older depressed adults. Treatment may be complicated by the presence of cognitive impairment, other comorbid medical disorders, and medications used to treat these disorders. Certain safety issues such as increased bleeding risk, hyponatremia, decreased bone density and falls may be associated with antidepressant treatment, may be more common in older depressed adults, and their consequences may be more severe in late life. These risks, however, need to be weighed against the hazards of untreated depression. With appropriate care, most older depressed patients can be successfully treated and a positive outcome can have a significant effect on the patient's quality of life.

The Impact of Psychotropic Medications on Bone Health in Youth

PURPOSE OF REVIEW

Psychotropics are prescribed to youth at rapidly growing rates and may negatively impact bone health. Little awareness exists of this association among prescribing providers. Childhood and adolescence are critical times for bone development. Understanding these effects and their management is important to informed psychotropic use.

RECENT FINDINGS

Through a variety of mechanisms, antidepressants, benzodiazepines, mood stabilizers, neuroleptics, and stimulants may all negatively impact pediatric bone health. This confers added risk of osteoporosis in a population already at high risk for suboptimal bone health. Awareness of psychotropic-mediated effects on pediatric bone development is clinically relevant to the use and monitoring of these agents. Clinicians can manage these effects through informed consent, vitamin D supplementation, lifestyle modifications, and reducing polypharmacy. For mood stabilizers, vitamin D level monitoring and secondary prevention is indicated. Future longitudinal studies and development of monitoring guidelines regarding psychotropic impact on bone health are necessary.

Risk of fractures at different anatomic sites in patients with irritable bowel syndrome: a nationwide population-based cohort study

This study was to investigate the fracture risk of irritable bowel syndrome (IBS) in comparison with non-IBS group. Our results found that IBS group has increased risk for fracture, in particular of the spine, forearm, hip, and hand.

INTRODUCTION

Patients with IBS might also be at increased risk of osteoporosis and osteoporotic fractures. Up to now, the association between IBS and the risk of fractures at different anatomic sites occurrences is not completely clear. We conducted a population-based cohort analysis to investigate the fracture risk of IBS in comparison with non-IBS group.

METHODS

We identified 29,505 adults aged ≥ 20 years with newly diagnosed IBS using the Taiwan National Health Insurance Research Database in 2000-2012. A comparison group was constructed of patients without IBS who were matched according to gender and age. The occurrence of fracture was monitored until the end of 2013. We analyzed the risk of fracture events to occur in IBS by using Cox proportional hazards regression models.

RESULTS

Patients with IBS had a higher incidence of osteoporotic fractures compared with the non-IBS group (12.34 versus 9.45 per 1000 person-years) and an increased risk of osteoporotic fractures (adjusted hazard ratio [aHR] = 1.27, 95% confidence interval [CI] = 1.20-1.35). Site-specific analysis showed that the IBS group had a higher risk of fractures for spine, forearm, hip, and hand than did the non-IBS group. With further stratification for gender and age, a higher aHR value for osteoporotic fractures in the IBS group was seen across all age groups in males, but seen in elderly females. In addition, female, elderly, low income, hypertension, coronary artery disease, cerebrovascular disease, and depressive disorders as independent osteoporotic fracture risk factors in IBS patients.

CONCLUSIONS

The IBS is considered as a risk factor for osteoporotic fractures, particularly in female individuals and fracture sites located at the spine, forearm, hip, and hand.