One of the strengths of this study is size of the population available and the reliability of information on prescribing and hospitalisations. Furthermore, the longitudinal nature of recording has two advantages. First, to our knowledge, this is the only study where duration of use analysis has allowed speculation on the effects of anti-depressants on bone. Second, this is the second study to evaluate the effect of 5-HTT inhibition on fracture risk estimates. In summary, our findings demonstrate that both SSRIs and TCAs increase the risk of hip/femur fracture in current users and that the risk increases with the degree of 5-HTT inhibition afforded by different

XL765 nmr anti-depressants. We did not find convincing evidence for a dose effect. The pathophysiology can be fall-related and/or bone-related. Further studies, including controlled prospective trials, are needed

to evaluate the relative contribution of disease-related and treatment-related effects to the increased risk of falls and hip/femur fractures GDC-0068 mw and to elucidate the pathophysiology. Until then, physicians prescribing anti-depressants should consider the elevated risk for fractures in elderly, possibly frail, people using anti-depressants and value the rule: “start low, go slow”. Acknowledgements The authors would like to thank Dr Helen Seaman for her assistance in the preparation of this manuscript for publication. Funding The current study has not been funded. Conflicts of interest Dr Van Staa and Dr de Vries also work for the General Practice L-NAME HCl Research Database (GPRD). GPRD is owned by the UK Department of Health and operates within the Medicines and Healthcare products Regulatory Agency (MHRA). GPRD is funded by the MHRA, Medical Research Council, various universities, contract research organisations and pharmaceutical companies. The division of Pharmacoepidemiology & Pharmacotherapy employing authors SP, TS and BT, HL, AE

and FV has received unrestricted funding for pharmacoepidemiological research from GlaxoSmithKline, Novo Nordisk, the private–public funded Top Institute Pharma (www.​tipharma.​nl, includes co-funding from universities, government and industry), the Dutch Medicines Evaluation Board and the Dutch Ministry of Health. Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. References 1. Cole MG, Bellavance F, Mansour A (1999) Prognosis of depression in elderly community and primary care populations: a systematic review and meta-analysis. Am J Psychiatry 156(8):1182–1189PubMed 2.