Should osteoporosis concerns trump anxiety meds?

DEAR DR. ROACH »

After several years of acting as a caretaker for my ailing parents and helping them pass,

I found myself filled with anxiety, which led to insomnia and troubled sleep. It felt like cortisol was racing through my body way too often. My doctor prescribed Lexapro — 10 milligrams of which I have been taking 5 mg daily — but recently I read that Lexapro and other SSRIs can also cause bone loss. As I have osteoporosis in my spine, I am now fearful of continuing with Lexapro. I have been on it for two months, and it’s greatly helped my sleep and pulled me out of any anxious state. But now worry is creeping in again in regard to osteoporosis. My mother had it, so I am genetically predisposed.

I am on robust bone-building supplements and doing weight-bearing exercise crafted specifically for spinal osteoporosis. I walk 3 to 4 miles daily. I now am considering trying the anti-anxiety med Buspar for a short time. Do you have any recommendations or thoughts on this in regard to osteoporosis?

— A.W.

ANSWER » Antidepressants, both Lexapro’s SSRI class and an older class called tricyclic antidepressants, do increase fracture risk. However, the major risk of fracture appears not to be from loss of bone density. The timing of fracture, which tends to occur soon after antidepressants are started if it does occur, argues against bone density loss as a cause. One hypothesis is that falls, a known risk when starting an SSRI or tricyclic antidepressant, is the cause of fracture.

Weight-bearing exercise and walking help both to increase bone mass and to reduce falls. These are particularly important for a person at risk for fracture due to osteoporosis.

Buspirone (Buspar) is an effective medication for anxiety disorders, especially generalized anxiety disorders. However, it is not an effective treatment for depression, and it can be surprisingly difficult sometimes to tell the difference between depression with anxiety as a prominent symptom and a primary anxiety disorder. So, I would recommend you have expert evaluation to separate these possibilities if considering Buspar. My experience is that Buspar is not quite as effective as SSRIs for anxiety disorders in most people.

Buspar does not seem to increase risk of fractures or loss of bone density, so it might be a good choice.

Contact Dr. Roach at ToYourGoodHealth@med. cornell.edu.

Keith Roach