Osteoporosis's link to depression
By the faculty of Harvard Medical School for The Harvard Medical School Adviser

Q: I'm in my mid-60s and have low bone density. A few years ago, I was diagnosed with depression and began taking Prozac. But I recently heard that antidepressant medications might be dangerous for people with osteoporosis. Should I stop taking my Prozac?

A: No. Don't stop taking your medication without first consulting with your clinician. Depression is a serious illness that can have profound emotional and physical consequences, ranging from suicide to heart disease, if it is left untreated. You and your clinician need to consider your individual risk before making any changes in treatment.

It's true that research has revealed links between depression and bone loss. But experts are still trying to sort out the underlying connections. It's a potentially serious problem given that as many as one woman in 10 suffers from depression, And more than 30 million women ages 50 and over have osteoporosis or are at risk for it. Osteoporosis is more common among people who, like you, have low bone density or a family history of the disease (see illustration). Smoking, being inactive, being thin and not getting enough calcium and vitamin D also raise the risk.

A recent study found that people ages 50 and older who regularly took antidepressants known as SSRIs (such as Prozac) had double the rate of fractures as people who were not taking these medications. But hints of a possible connection date back to the 1980s, when studies found that depression was common in people living with the pain and disability of osteoporosis. At first, experts reasoned that the pain was responsible for the depression. But during the 1990s, depression began to emerge as a possible cause of bone loss rather than a result. Scientists studied women who didn't have osteoporosis symptoms or even know they had the condition. Using new technologies, they found lower bone-mineral density (BMD) in those who were depressed. Moreover, the link was found both in younger women (where such bone loss is uncommon) and in women past menopause (where bone loss is common).

Several studies found that depressed women have higher levels of a stress hormone known to cause bone loss. Depression may be a risk factor for osteoporosis in other ways. For example, people who are very depressed may not take care of themselves by eating right and exercising properly. A healthy diet and regularly physical activity can help prevent bone loss.

The findings on depression and bone loss raise other questions: Are all depressed people at risk for osteoporosis and fractures, or only those taking antidepressants? If certain medications are part of the problem, is it because they can increase the risk of falling, particularly in older people? Or is it because the drugs actually weaken bone? The available studies show mixed results and don't always take into account all potentially relevant factors. For example, some women in the most recent study were also taking other medications linked to low bone density.

It may be a long time before the depressionosteoporosis connection is fully understood. In the meantime, talk to your clinician about getting regular bone-density tests. And be sure you follow recommendations to reduce your risk for bone loss. For example, make sure you get adequate calcium (1,000 to 1,200 milligrams per day) and vitamin D (400-800 IU/day). Many women, particularly those living in the northern United States, don't get enough vitamin D.

Antidepressants are a vital part of treatment for people with major depression. They can help you feel better and allow you to participate more fully in psychotherapy and other activities. But feeling sad because of a personal loss or painful life event -- the death of someone close to you, a divorce, job loss or other major upset -- may not always call for antidepressant therapy. Talking to a counselor or therapist might be enough to help you through these difficult times. Regular exercise -- 30 minutes a day, most days of the week -- also improves mood. And weight-bearing and resistance exercises (such as walking, weight lifting and aerobics) can help protect your bones as well.

Depression can make life difficult, and so can osteoporosis. Fortunately, you don't have to choose between these two common problems; a comprehensive treatment plan can help you cope with both.

Copyright 2007 the President and Fellows of Harvard Developed by Harvard Health Publications (www.health.harvard.edu) . Distributed by UFS. Submit questions to harvard_ adviser@hms.harvar d.edu.