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Antidepressants May Increase Your Risk of Spinal Fracture

ssris falls and fracture risk in spinal stenosis elderlyAccording to a new study, hypnotic sleep medications and SSRIs may increase the risk of osteoporotic and hip fractures in older adults. Selective serotonin reuptake inhibitors (SSRIs) are a popular type of antidepressant and, as back pain is often associated with depression, those with spinal stenosis may be particularly at risk of this complication.

Presenting this latest research at the American Society for Bone and Mineral Research (ASBMR) 2014 Annual Meeting, first author Daniel Sundh, from the Center for Bone and Arthritis Research at the Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Sweden, noted that current fracture risk assessment tools such as FRAX only account for the use of oral glucocorticoids in determinining medication-related increased fracture risk. The use of SSRIs and hypnotic medications for insomnia should also be brought into consideration, says Sundh.

Do SSRIs Increase Fall Risk or Damage Bone Health?

The mechanism for this increase in risk may not be to do with changes in bone turnover but, rather, be a result of an increased risk of falling in those taking sleep medications and certain antidepressants. However, although the researchers reached this conclusion in the study, they did not actually show that less falls resulted in less fractures, meaning that it is difficult to determine the reasons behind the apparent association of SSRIs and hypnotics with fracture risk.

The researchers looked at the records of almost 130,000 seniors, making this one of the largest studies of its kind. This large cohort is certainly a strength of the study but it also created a limitation when adjusting for all FRAX variables. One such consideration was the lack of adjustment for the reason for these patients taking SSRIs and/or hypnotic medications.

Back Pain and Depression – A Dangerous Combination?

As mentioned a moment ago, back problems can themselves be associated with depression and some patients actually take antidepressants as part of their pain management program for neuropathic pain. Additionally, people with back problems like spinal stenosis may have difficulties sleeping, leading to them being prescribed hypnotic sedatives.

In all, the researchers found over 15,000 fall-related injuries, with 6730 fractures related to osteoporosis, and some 2557 hip fractures. Almost half (40.9%) of those experiencing such injuries had suffered at least one earlier fall.

SSRIs were being used by 17.4% of participants in the study, and 19% were taking hypnotic medications for insomnia. The authors found a significant association between the use of these drugs and the prevalence of fall-related injuries. The prevalence for SSRI users was 50.7% vs 38.8% for those not taking SSRIs. There was a 45% prevalence for falls with hypnotic medication use vs 40% for no hypnotic use.

People taking SSRIs had a 22.4% rate of osteoporotic fracture (vs 15.2% for no SSRI use), while hypnotic use had an associated 19.5% rate of fractures (vs 15.7% for no hypnotic use). Hip fractures occured in 2.3% of SSRI users vs 1.9% of those not taking SSRIs. The rate for hypnotic use was 2.2% vs 1.9% for no hypnotic use.

30% Increase in Fracture Risk for SSRI Users

Further statistical analysis, adjusting for known risk factors like age, sex, height and weight, secondary osteoporosis, prevalent osteoporotic fracture, glucocorticoid use and rheumatoid arthritis, revealed that the increased risk for hip fracture was 30% among SSRI users and 21% for those using hypnotics. Osteoporotic fractures also had a significant association with these two types of medication after adjusting for other risk factors.

Some of the most commonly prescribed hypnotic sleep medications include:

  • Zolpidem
  • Eszopiclone
  • Zaleplon

These drugs have, in recent years, been considered the safer option for helping with sleeping problemsas they do not have the same addictive qualities as benzodiazepines. However, the safety of such drugs has been called into question before and this latest research suggests another potential negative side effect of such hypnotics.

Further studies are clearly needed to look at the potential adverse effects of these medications on bone turnover, balance, and other factors that increase the risk of falls. In the meantime, it seems sensible for physicians treating patients with spinal stenosis and other conditions that can be caused by osteoporosis to consider the potential increase in risk of fracture with SSSRIs and hypnotics.


American Society for Bone and Mineral Research (ASBMR) 2014 Annual Meeting. Abstract 1015. Presented September 14, 2014.

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