What is Atypical Antipsychotic Effect on Bone Mineral Density?
According to studies by the National Research Council and Institute of Medicine, between 14% and 20% of young people have a psychiatric illness, and about 80% of these individuals take multiple mental health medications at the same time, including atypical antipsychotics. The U.S Food and Drug Administration (FDA) has approved these drugs for specific mental health conditions, such as Tourette’s and other tic disorders, symptoms linked to developmental delays, autism, bipolar disorder, and schizophrenia. Additionally, antipsychotics are commonly used “off-label” (without explicit FDA approval) to manage emotional and behavioral symptoms in young people.
Research has found that about 17% of young people with autism take antipsychotics. Risperidone is the most frequently prescribed (55%), followed by aripiprazole (35%). In contrast, adults in psychiatric hospitals are mainly given olanzapine (51%), followed by risperidone (23%). It’s important to note that antipsychotics can have significant side effects, such as weight gain, high cholesterol levels, unchecked diabetes, and increased levels of a hormone called prolactin. These side effects are especially common with first-generation antipsychotics due to their strong effect on dopamine receptors.
Research has also shown that up to two-thirds of patients on atypical antipsychotics suffer from reduced bone density, which can lead to osteoporosis. The risk of bone disease and fractures increases with these medications. They can either directly affect bone density or indirectly lead to weight gain by reducing physical activity or causing excessive drowsiness. Evidence shows that early onset osteoporosis in patients with mental illnesses like schizophrenia may be linked to long-term exposure to antipsychotics. The use of these drugs can increase the risk of hip fractures by up to 1.6 times. Due to these side effects, the U.S. FDA includes a warning in the prescription details of these medications.
What Causes Atypical Antipsychotic Effect on Bone Mineral Density?
Antipsychotic medications can have harmful effects on bone growth. These medicines can upset the balance of bone metabolism by blocking dopamine receptors, leading to conditions called hyperprolactinemia and hypogonadotropic hypogonadism. Hyperprolactinemia directly affects bone growth through its interaction with prolactin receptors on cells involved in bone formation, known as osteoblasts.
Increased levels of prolactin can decrease the body’s ability to absorb calcium and can stimulate the release of parathyroid hormone-related peptides which increase the breakdown of bone. Antipsychotic medications can also slow down the maturation of bones by influencing serotoninergic and adrenergic receptors found on bone-forming (osteoblast) and bone-breaking (osteoclast) cells.
High cortisol levels are often seen in patients with mental health conditions who are receiving antipsychotic treatment, creating yet another risk factor for weakened bone mineralization. Patients taking multiple medications for mental health conditions, such as antipsychotics and SSRIs, have a higher risk of bone deformities.
Lastly, teenagers with severe and long-term mental health problems are at a higher risk for low vitamin D levels because of poor nutrition, lack of exercise, insufficient exposure to sunlight, and high substance abuse. These factors enhance the potential harmful effects of antipsychotics on the mineralization of bones.
Risk Factors and Frequency for Atypical Antipsychotic Effect on Bone Mineral Density
Osteoporosis is a global issue affecting around 200 million people and is responsible for causing a fracture every 3 seconds. This bone condition primarily develops as an effect of aging. However, it can also occur in younger individuals due to long-term use of certain medicines like antipsychotics, termed secondary osteoporosis.
- Nearly 85% of crucial bone growth happens before the age of 18.
- A decrease of 5 to 10% in peak bone density can greatly raise the risk of fractures or bone disease in later life.
Research has found that osteopenia, a condition of bone loss that can lead to osteoporosis, is more common in people diagnosed with schizophrenia. Among these individuals, 44% of males and 48.9% of females were found to have osteopenia, much higher than the 9.2% of males and 21% of females without schizophrenia.
A noteworthy detail is that elderly patients with schizophrenia have twice the risk of osteoporosis compared to those without the disorder. In fact, up to 65% of schizophrenia patients taking antipsychotics experience osteopenia, thereby increasing their chance of developing osteoporosis. These drugs increase the levels of prolactin, a hormone linked to osteoporosis, in both males and females. Despite osteoporosis often being referred to as a “women’s disease,” it affects both sexes equally when caused by raised prolactin levels.
Interestingly, the impact of antipsychotics on bone mineralization, the process of depositing minerals on the protein scaffold of the bone, was found to be the same in both sexes. This is attributed to hyperprolactinemia, a condition of elevated levels of prolactin, which affects levels of gonadotropins, hormones that influence growth and function of the sex organs. However, hyperprolactinemia’s prevalence is higher in postmenopausal women. A specific antipsychotic medicine, Risperidone, has been shown to cause an early onset and prolonged duration of hyperprolactinemia.
Signs and Symptoms of Atypical Antipsychotic Effect on Bone Mineral Density
Osteopenia, often referred to as a ‘silent disease’, usually doesn’t show any symptoms until a bone fracture occurs. This can lead to late diagnosis as its general symptoms don’t clearly point to the disease. When bone mineral density is reduced, symptoms like all-over bone pain, tenderness, muscle weakness, and frailty-related fractures may appear.
Bone fractures in osteopenia, medically termed as osteomalacia (where bone mineral density or BMD is over 1 but less than 2.5 standard deviations), are generally unique compared to those in osteoporosis (where the deviations are 2.5 times below the healthy population score). Osteomalacia can be suspected when there are fractures in the pelvic bone, foot, tibia, or ribs. Classic indicators of osteoporosis are fractures in the neck of the femur and ‘wedged’ spinal fractures.
- All-over bone pain
- Tenderness
- Muscle weakness
- Frailty-related fractures
Testing for Atypical Antipsychotic Effect on Bone Mineral Density
There are several methods currently used to measure bone mineral density (BMD), which is essential for diagnosing conditions like osteoporosis. These methods include metacarpal morphometry, bone ultrasound (QUS), computed tomography (QCT), dual-energy X-ray absorptiometry (DXA), and magnetic resonance imaging (MRI).
A regular bone X-ray can only detect a decrease in BMD when bone loss exceeds 40%, so it’s not the best tool for regular check-ups. The QCT method is excellent because it measures the volume of bone and can differentiate between the compact bone on the outside and the spongy bone inside.
There’s an alternative technique, Peripheral (PQCT), which exposes patients to less radiation and is more child-friendly. The most common tool used to assess bone density is DXA. It’s a winning choice because of its low radiation exposure, accurate results, and lower cost compared to QCT. However, DXA isn’t perfect. It doesn’t directly measure actual bone volume or provide detailed BMD assessments. In some rare cases, a bone biopsy may be needed to confirm the diagnosis.
Treatment Options for Atypical Antipsychotic Effect on Bone Mineral Density
There are no established guidelines for testing the levels of the hormone prolactin or assessing bone health during the usage of antipsychotic drugs. Furthermore, the relationships between antipsychotic medications, prolactin levels, and bone issues are not clearly defined in either children or adults. Similarly, there’s no obvious link between a patient’s age, treatment length, sex, or race and bone density in those receiving psychiatric care as compared to the general population.
In order to enhance bone density in psychiatric patients on long-term antipsychotics, executing proactive steps is suggested. These steps can include lifestyle changes: a program to prevent falls, monitoring prolactin levels, taking vitamin D supplements, and refraining from smoking and alcohol.
Methods such as whole-body vibration therapy, which mechanically stimulates bone, might yield positive results. Medications such as bisphosphonates, raloxifene, denosumab, and glucagon-like peptide-1 (GLP-1) are commonly used in treatment. Additionally, teriparatide, anabolic treatments, and hormone replacement therapy present other avenues to boost bone mineral density.
What else can Atypical Antipsychotic Effect on Bone Mineral Density be?
Bones can become less dense and weaker due to conditions like osteoporosis or osteomalacia. This can happen as a standalone problem or because of other conditions or factors:
- Hormonal problems like underactive gonads, conditions affecting the pituitary gland, diabetes, or an overactive thyroid
- Autoimmune and chronic illnesses like rheumatic conditions, ongoing kidney, lung, and digestive tract diseases, organ transplant conditions, and granuloma-forming diseases
- Bone marrow and cancerous conditions, such as multiple myeloma, lymphomas, leukemias, cancer spreading to bones, and chronic anemia
- Medications like excessive steroids, seizure medications, TB drugs, long-term use of blood thinners, cyclosporin A or methotrexate
- Nutritional deficiencies of vitamins like K, D, C, and overall poor nutrition
- Genetic disorders like brittle bone disease, homocystinuria, Ehlers-Danlos syndrome, and Marfan syndrome
- Lifestyle factors like smoking, heavy drinking, being unable to move for a long time, and losing weight
By understanding the possible causes, the proper tests can be done to identify which one is creating the problem.
What to expect with Atypical Antipsychotic Effect on Bone Mineral Density
If detected early and managed correctly, bone density damage caused by antipsychotic medication generally has a good outlook. However, if left untreated, it often leads to chronic pain, softening of the bones, fragile bones, and even bone fractures. It’s important to note that bone fractures significantly raise the risk of illness or death among psychiatric patients. Adopting healthier lifestyle practices, incorporating exercise, and consuming a balanced diet can help reduce the chances of complications. Sometimes, additional medication may also be needed.
Possible Complications When Diagnosed with Atypical Antipsychotic Effect on Bone Mineral Density
Antipsychotic medications can lead to several hormonal and metabolic side effects. These might include weight gain, abnormal lipid levels, unregulated diabetes, metabolic syndrome, changes to the heart’s electrical activity, involuntary movements, inflammation in the heart, weakened bone marrow, cataracts, elevated hormone levels causing lack of menstruation and sexual side effects.
One potential side effect of antipsychotics that might not be thoroughly studied or recognized by healthcare providers is reduced bone mineral density, which could lead to fractures. This could be due to the medication reaching the bone marrow and central nervous system, resulting in these conditions.
Given the large number of patients taking these medications, it’s crucial for both healthcare providers and patients to understand the level of risk, recognise signs early, and seek potential preventative measures or treatments for these drug-induced bone changes.
Common Side Effects:
- Weight gain
- Abnormal lipid levels
- Unregulated diabetes
- Metabolic syndrome
- Changes to the heart’s electrical activity
- Involuntary movements
- Inflammation in the heart
- Weakened bone marrow
- Cataracts
- Elevated hormone levels causing impaired menstruation
- Sexual side effects
- Decreased bone mineral density
- Fractures
Preventing Atypical Antipsychotic Effect on Bone Mineral Density
It’s important for the patient’s family to understand potential complications related to bone mineral density. Consulting with a psychiatrist or pharmacist can be of great help in choosing the right antipsychotic medication, figuring out the best dosage, and exploring safer alternatives. Medical providers should be prepared to quickly identify and assess any potential side effects from the antipsychotic medicines. This includes conducting regular check-ups to catch any complications early on.
Furthermore, a group approach where mental health professionals work closely with each other and the patient’s family is necessary. Open communication within this team is key to the patient’s well-being and treatment plan.
