The strengths of these studies include large population-based samples, the OSTPRE female sample from Finland and the GOS male sample from Australia. Bone health was studied against several indicators of mental health i.e. self-reported life satisfaction, hospitalization due to depression and lifetime MDD episodes as well as against use of antidepressant medication.
Measuring bone health by using both DXA with several measurement sites and calcaneal QUS on the same GOS population strengthened the liability of the found results. A wide age range was allowed in the GOS studies, whereas the narrow age range increased the homogeneity of the OSTPRE studies. High response rates allowed also estimation of the representative population effects. These data sets included extensive questionnaire and additional registry based data. Thus, it was possible to adjust for several potential confounding factors. When investigating antidepressant use, adjustment for depression improved the reliability of the results. The same was applied, when life satisfaction or depression was the exposure and medications the covariates.
Epidemiologic studies have always a risk of confounding. Information bias is possible in studies based on enquiries. Inaccurate recall or response may have affected the found associations.
However, it is not likely that these inaccuracies differed by outcome or biased the relationships found in these studies. The present studies included both cross-sectional and longitudinal studies which give valuable but different perspectives to the study questions, although, cross-sectional studies do not allow investigation of causal relationships. Using self-reported antidepressant data and the cross-sectional study designs did not allow for the effects of duration of use or dosage to be explored. Also the investigation of antidepressant subgroups was restricted due to study power constraints. In the OSTPRE study, antidepressant use was derived from the prescription register which provides a higher accuracy even if use is occasional. A limitation in the prescription register is that it does not verify the actual use or the exact daily dosage. Participants might have also discontinued the medication. In addition, prescription register provides information only for reimbursement packages which have been purchased from a pharmacy.
8 Conclusions
Studies of this thesis showed that poor mental health, either diagnosed depression or decreased life satisfaction, has negative associations on bone in both postmenopausal women and in men.
These studies also showed negative associations between TCA and SSRI use and bone in postmenopausal women. In addition, use of ‘other antidepressants’ was associated with bone loss in low-weight women, as was the use of any antidepressants in lower weight men.
Self-reported medication use via postal enquiry seems to be a sufficient indicator of regular use of antidepressant medication and any psychoactive medication use for subjects with severe psychiatric disease. However, prescription register data gives a more accurate indication of those who are using these medications irregularly or suffer from less severe mental disorders.
9 Recommendations
Severe depression as well as milder psychological symptoms i.e. life dissatisfaction seems to be associated with poor bone metabolism. Prevention of depression, its early detection and appropriate medical care may thus be important issues in the prevention and care of osteoporosis or lowered bone density in both men and women. Furthermore, focusing on improving subjective well-being might be one of the approaches that should be considered to decrease adverse effects of aging on bone.
The risk of effects on bone should be taken into account when prescribing antidepressants for men and women. For postmenopausal women with already heightened risk of osteoporosis, long-term treatment of depression with high doses of TCAs and SSRIs should be monitored and interrupted if use is not required.
Further research with sufficient sample size focusing on subgroups of antidepressants and body weight on bone health is needed. Differentiation of subtypes of depression (melancholic/atypical) in these studies might also provide additional information.
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