Severe mental illness linked to higher risk of fragility fractures in older adults

People over the age of 50 who have severe mental illness are more likely than the general population to experience fragility fractures but may be less likely to get a diagnosis for osteoporosis, finds a new study led by UCL researchers.

Fragility fractures are broken bones that occur after a minor fall or impact that wouldn't usually cause a fracture. This kind of ailment often occurs in people with osteoporosis, a disease that weakens the bones and makes them more likely to break.

The study, published in the British Journal of General Practice, analysed the GP records of over 440,000 people over the age of 50 between 2000 and 2018, to examine the diagnosis of osteoporosis and fragility fractures in people who have been previously diagnosed with severe mental illness, compared to the general population.

Severe mental illness (SMI) refers to mental health problems such as schizophrenia, bipolar disorder or other forms of psychosis that are often so debilitating that they have a great impact on a person's ability to work and function on a daily basis.

People with SMI often have poor physical health and frequently develop chronic physical health conditions at a younger age than people without SMI. These chronic conditions include obesity, asthma, diabetes, chronic obstructive pulmonary disease (COPD), coronary heart disease, stroke, heart failure and liver disease. People with SMI are also at increased risk of developing more than one of these chronic conditions.

In their new study, the researchers found that a diagnosis of severe mental illness was also a risk factor for fragility fractures in both men and women.

However, men with severe mental illness were twice as likely to have a record of a fragility fracture compared to a diagnosis of osteoporosis, meaning that osteoporosis may not be promptly diagnosed in men with severe mental illness.

Similarly, women with severe mental illness were more likely to have a record of fragility fracture compared to a diagnosis of osteoporosis if they were 50-54 years old or above the age of 80, meaning that osteoporosis may be underdiagnosed in women with SMI who belong to these age groups.  

As a result of their findings, the researchers are now calling for interventions, such as bone density measurement, treatment of osteoporosis with medication, and non-pharmacological interventions such as exercise and dietary advice, to be considered in people with severe mental illness.

The researchers did not look into the reasons for their findings, but lead author, Dr. Christina Avgerinou (UCL Epidemiology & Health) who is an academic GP, said there could be a number of reasons behind them.

The physical health of people with severe mental illness is often neglected, and this group of patients have higher rates of premature mortality.

We have demonstrated that a diagnosis of severe mental illness 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 also suggests that osteoporosis is underdiagnosed in both men and women with these kinds of conditions.

Our study did not examine the reasons behind this. However, it can be hypothesized that people with SMI are not aware about osteoporosis to the same extent as people without SMI, or that people with SMI have other comorbidities that are a priority for management by primary care practitioners.

Other reasons could include that people with SMI may not engage with physical health checks in primary care to the same extent as people without SMI, or that osteoporosis starts earlier in this age group which means it is less likely to be detected before a fracture occurs."

Dr. Christina Avgerinou, UCL Epidemiology & Health

This study was funded by the National Institute for Health and Care Research (NIHR) and School for Primary Care Research and was adopted by NIHR Applied Research Collaboration (ARC) North Thames.