Highlights
- •Depression has been associated with increased risk of fractures.
- •This longitudinal study confirmed that exposure to depression increases the risk of fractures, but the effect of this association is modest.
- •In this older cohort with multiple competing risks for fractures, exposure to antidepressant medications (including SSRIs) did not increase fracture risk.
- •The management of older adults with depression should include strategies for fracture prevention.
Abstract
Introduction
Fractures are common and disabling health events, particularly later in life. The
presence of clinically significant depressive symptoms has been associated with increased
risk of fractures, and we designed the present study to clarify if this association
is likely to be causal or due to the confounding effect of measures associated with
both fractures and depression.
Method
Cohort study of a community-derived sample of 4224 men aged 70 to 88 years at the
start of the follow-up period of up to 17 years. Clinically significant symptoms of
depression were defined as a recorded diagnosis of depressive episode in the Western
Australian Data Linkage System (WADLS) or by a total score of 7 or greater on the
15-item Geriatric Depression Scale. Health contacts associated with fractures were
retrieved from WADLS. Other measures included age, past history of fractures, education,
smoking, frailty, poor vision, falls, medications, and the concentration of vitamin
D, homocysteine, hsCRP and testosterone. Death was considered a competing risk for
fractures.
Results
911 (21.6%) participants had a bone fracture during follow-up. After adjustment for
multiple potential confounders, past and current depression were associated with an
increase in the risk of novel fractures; respective odds ratios were 1.41 (95%CI =
1.03, 1.93) and 1.64 (95%CI = 1.20, 2.25). Parsimonious competing risk regression
showed that both past and current depression were associated with an increase in the
risk of novel fractures: sub-hazard ratio = 1.29 (95%CI = 1.03, 1.63) and 1.27 (95%CI
= 1.05, 1.55) respectively. Estimation of confounding due to unmeasured factors showed
that a small additional effect could potentially dilute the association between depression
and fractures.
Discussion
History of clinically significant symptoms of depression is associated with an increased
risk of future fractures. This association may be due to multiple other associated
risk factors, both measured and unmeasured, but nevertheless the presence of depression
should alert clinicians to the need to develop a management plan that includes the
management not only of depression but also of fracture risk.
Keywords
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Article info
Publication history
Published online: December 21, 2020
Accepted:
December 15,
2020
Received in revised form:
October 16,
2020
Received:
June 12,
2020
Identification
Copyright
© 2020 Elsevier B.V. All rights reserved.
