Osteoporosis and fragility fractures in people with Severe Mental Illness in the UK

PROJECT STATUS: Completed
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START DATE AND DURATION: December 2020 - November 2022
Summary

Severe Mental Illness (SMI) has been associated with reduced bone mineral density (BMD) and increased risk of fractures but the mechanisms are not clear.

A review has shown that although prolactin-raising antipsychotic medication was associated with lower BMD, there were inadequacies in the consideration of other risk factors for osteoporosis. A Canadian study exploring fractures across the whole spectrum of mental health disorders showed that antipsychotic medication increased the risk of hip fracture.

This project explored the incidence of falls and fractures in people with SMI (schizophrenia, bipolar disorder or other psychosis), taking into account a range of other factors. These include age, gender, ethnicity, personal history and family history of hip fracture, weight/BMI, smoking, alcohol, prescription of antipsychotics, benzodiazepines and medication for osteoporosis.

Key Findings
In total 444,480 people were included (SMI N=50,006; unexposed N=394,474). In men, diagnosis of SMI increased the likelihood of OP diagnosis, with differences mainly observed amongst the youngest (50-54y:HR=2.12; 95%CI 1.61-2.79) and oldest (85-99y:HR=2.15; 95%CI 1.05-4.37), and also increased the risk of FF across all ages. In women, SMI increased the risk of OP diagnosis only in those aged 50-54y:HR=1.16; 95%CI 1.01-1.34, but increased the risk of FF across all ages. There were more than twice as many men with SMI with FF records than with OP diagnosis: FF:OP=2.10, compared to FF:OP=1.89 in men without SMI. The FF:OP ratio was 1:56 in women with SMI vs. 1:11 in women without SMI.
Conclusion: SMI is associated with increased likelihood of fragility fractures and osteoporosis underdiagnosis. Interventions should be considered to mitigate the increased risk of fractures in people with SMI.
Our study found an increased risk of fragility fractures in people aged ≥50 with a diagnosis of SMI. It is not clear if this difference could be due to antipsychotic medication, an underlying biological mechanism of an association between osteoporosis and SMI, other factors such as lack of exercise or differences in osteoporosis management. Further research is needed to explore inequalities in osteoporosis screening and treatment in the presence of SMI.
Primary care clinicians need to become aware of the increased fracture risk in people with SMI, which could be addressed during/following physical health checks. Fracture risk assessment and appropriate osteoporosis treatment as indicated may need to be included in the annual comprehensive care plan in people with SMI. Advice on diet and resistance training to prevent osteoporosis and fractures should also be evaluated.
IMPACTS
We demonstrated that a diagnosis of SMI is a risk factor for fragility fractures in both men and women, accounting for age, social deprivation, smoking, alcohol, and body mass index
Our data suggest that osteoporosis is underdiagnosed in men and women with SMI
Interventions should be considered to screen for osteoporosis and mitigate the increased risk of fractures in people with SMI
Partners & Collaborators

University College London (UCL)

University of Leeds School of Medicine

Bradford Institute for Health Research

Lead Investigator
Christina Avgerinou (UCL)
Kate Walters (UCL)
Investigating Team
Irene Petersen (UCL)
David Osborn (UCL)
Robert West (Bradford Research)
Andrew Clegg (Leeds School of Medicine)
Resources
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