Integrating mental health into fracture liaison services: an attribution-first policy approach to depression, concerns about falling and pathway loss

Fracture liaison services (FLSs) improve delivery of secondary fracture prevention, yet eligible patients are still lost between identification, assessment, treatment recommendation, initiation, rehabilitation and follow-up. This Policy and Practice Review asks whether depression and concerns about falling should inform FLS policy, and how they could be addressed without displacing core fracture-prevention work. We synthesized structured PubMed searches with targeted appraisal of the International Osteoporosis Foundation Capture the Fracture architecture, cross-national FLS studies, clinical guidelines, audit documents and implementation-science frameworks. Evidence, derived mainly from hip-fracture populations, links depressive morbidity and mental-disorder indicators to poorer recovery or lower treatment initiation, and links concerns about falling to activity restriction and functional outcomes. These findings are prognostic rather than causal: pain, frailty, cognition, environment and service organization remain incompletely controlled. Intervention studies can improve mood or falls-related confidence without consistently improving objectively measured behavior, and no trial identified in this review used completion of an FLS engagement node as its primary outcome. Existing international and national frameworks make core FLS processes measurable, but they do not provide a consistent, auditable linkage between a non-completed node, the source of the attributed reason, the response delivered and the subsequent outcome. The England and Wales Fracture Liaison Service Database (FLS-DB) is used as a worked policy case: it records selected states such as non-attendance, patient decline and non-contactability, but its node-specific denominators and distributed fields cannot reconstruct the whole pathway. We compare four options: the status quo; cross-node reason attribution; targeted case finding linked to a named response; and a universal stepped pathway. Current evidence supports a staged sequence—attribution first, targeted measurement only where response capacity exists, and multicentre evaluation before universal standards. Evaluation should protect informed refusal, report reach and equity, preserve existing FLS performance and use prespecified stopping rules. Mental-health integration should therefore be treated as a testable quality-improvement strategy, not an established standard of care.