Lipid-lowering therapy and violent death: Is depression a culprit?

Screening, diagnosis & monitoring of depression/distress in CHF patients

Objective and validated measures of depression/distress (anxiety and anger) are available and readily usable at the bedside or in clinic. Foremost among these is the Patient's Health Questionnaire--an adaptation of DSM IV criteria for Major Depressive Disorder that permits administration and scoring by nursing or physician personnel, and quantification of the intensity of depression. A score of 10 or greater indicates a need for evaluation/treatment. Because of patient denial/minimization/alexithymia, PHQ negatives should undergo further screening by having a spouse or friend complete a depression/distress rating scale. The only standardized, normed, and validated spouse/friend scale presently available is the Ketterer Stress Symptom Frequency Checklist, which is available by internet.

Psychological factors affecting a medical condition: ischemic coronary heart disease

The criteria for scientific validation of the entities currently subsumed under the DSM-IV category of "Psychological Factors Affecting a Medical Condition" have never been clearly enumerated. Historically, its precursor category ("Psychophysiological Disorder") was rarely used, and predicated upon clinical observation of personality styles among patients with specific physical illnesses, or clinical observations relating psychosocial events and symptom exacerbation. Because of logical flaws with either of these methods, clarification of the most rigorous criteria for demonstrating a cause-effect relationship is necessary. With the increase in well-designed and carefully executed epidemiological and treatment studies, this diagnostic category has evolved into an arena where cutting-edge insights and therapies are becoming available for a growing variety of medical conditions, especially ischemic coronary heart disease. The present article reviews the nature of the scientific evidence necessary to accept an etiological or aggravating role for psychological events.

Cholesterol levels in mood disorders: high or low?

OBJECTIVES

To assess cholesterol levels in patients with mood disorders.

METHODS

All consecutively admitted patients meeting inclusion criteria (n = 50) who were hospitalized in an affective disorders unit received assessments of cholesterol levels. Correlations were made with diagnosis using DSM-IV criteria, current mood states, and other clinical and demographic features of illness. Exclusion criteria included current alcohol abuse, medical illnesses that could influence cholesterol levels, eating disorders, and age greater than 70 years.

RESULTS

Cholesterol levels did not differ based on diagnostic status of unipolar depression or bipolar disorder. In the total sample, cholesterol levels were lower in patients with current manic (170.2 +/- 38.9, p = 0.05) and depressive (182.0 +/- 42.0) than in mixed (226.4 +/- 43.3) episodes (p = 0.05). In subgroups of patients with bipolar disorder, manic episodes (169.9 +/- 38.8, n = 9) were associated with lower cholesterol levels than depressive (201.0 +/- 49.4) or mixed (226.4 +/- 44.4) episodes (p = 0.02 for comparison of manic and mixed episodes). Body mass index (BMI), age, alcohol use, and gender did not account for these findings.

CONCLUSIONS

Cholesterol levels were lower in manic and depressive than in mixed episodes. No differences were found between diagnoses of unipolar or bipolar mood disorders. Cholesterol may be a state rather than a trait function, and may be influenced by the acute mood state.

Relations of trait depression and anxiety to low lipid and lipoprotein concentrations in healthy young adult women

OBJECTIVE

Recent evidence suggests that naturally occurring low cholesterol concentrations (<4.14 mmol/liter) are associated with depression as well as poor psychological health. For the most part, these associations have been observed in men. The current study assessed the relation of naturally occurring low lipid and lipoprotein concentrations to trait measures of depression and anxiety in 121 healthy young adult women.

METHODS

Fasting lipid samples were collected at the same time as health history. Trait depression and anxiety were assessed using the Neuroticism, Extraversion, Openness-Personality Inventory (NEO-PI) depression subscale and Spielberger's Trait Personality Inventory (STPI) anxiety subscale. Analyses were conducted using both univariate and multivariate procedures.

RESULTS

NEO depression was inversely associated with total cholesterol (p = .027), triglycerides (p = .012), and the ratio of total cholesterol to high-density lipoprotein cholesterol (p = .059). Similarly, STPI anxiety was inversely associated with total cholesterol (p = .002), low-density lipoprotein cholesterol (p = .016), triglycerides (p = .024), and ratio of total cholesterol to high-density lipoprotein cholesterol (p = .075). These associations were significant after adjustment for age, body mass index, physical activity, oral contraceptive use, and hostility. Neither depression nor anxiety was associated with high-density lipoprotein cholesterol. Univariate analyses indicated that women with low total cholesterol concentrations (<4.14 mmol/liter), relative to those with moderate to high cholesterol levels, were more likely to have higher scores on the NEO depression subscale (27 of 69 (39%) vs. 10 of 52 (19%)) and STPI anxiety subscale (24 of 69 (35%) vs. 11 of 52 (21%)).

CONCLUSIONS

In healthy young adult women, low lipid and lipoprotein concentrations are inversely associated with trait measures of depression and anxiety. These findings are independent of age, body mass index, physical activity, and other factors known to influence lipid concentrations.

Assessing the observed relationship between low cholesterol and violence-related mortality. Implications for suicide risk

Health advocacy groups advise all Americans to restrict their dietary intake of saturated fat and cholesterol as an efficacious and safe way to lower plasma cholesterol concentrations and thus reduce the risk of coronary heart disease and other atherosclerotic disorders. However, accumulating evidence suggests that naturally low or clinically reduced cholesterol is associated with increased nonillness mortality (principally suicide and accidents). Other evidence suggests that such increases in suicide and traumatic death may be mediated by the adverse changes in behavior and mood that sometimes accompany low or reduced cholesterol. These observations provided the rationale for an ongoing series of studies in monkeys designed to explore the hypothesis that alterations in dietary or plasma cholesterol influence behavior and that such effects are potentiated by lipid-induced changes in brain chemistry. In fact, the investigations in monkeys reveal that reductions in plasma cholesterol increase the tendency to engage in impulsive or violent behavior through a mechanism involving central serotonergic activity. It is speculated that the cholesterol-serotonin-behavior association represents a mechanism evolved to increase hunting or competitive foraging behavior in the face of nutritional threats signaled by a decline in total serum cholesterol (TC). The epidemiological and experimental data could be interpreted as having two implications for public health: (1) low-cholesterol may be a marker for risk of suicide or traumatic death and (2) cholesterol lowering may have adverse effects for some individuals under some circumstances.