Serum cholesterol and aggression in hospitalized male forensic patients

Disentangling the relationship between cholesterol, aggression, and impulsivity in severe mental disorders

OBJECTIVE

Low total cholesterol has been linked with adverse mental symptoms such as aggression and impulsivity in severe mental disorders (SMDs). This putative association may affect the clinician's decision making about cholesterol lowering in this patient group. Here, we investigated the associations between cholesterol levels, aggression, and impulsivity in a large representative sample of in- and outpatients with SMD.

METHODS

Patients with schizophrenia- or bipolar spectrum disorders (N = 1 001) underwent thorough clinical characterization and blood sampling (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol). Aggression was characterized by the Positive and Negative Syndrome Scale Excited Component. Impulsivity was measured with the Barratt Impulsiveness Scale in a subsample of patients (N = 288). We used a multinomial logistic regression model to analyze the association between cholesterol and aggression and a multiple linear regression model to analyze the association between cholesterol and impulsivity, while controlling for confounders.

RESULTS

We found no significant associations between cholesterol levels and aggression or impulsivity. There were no significant interactions between cholesterol and diagnostic group or inpatient versus outpatient status. Controlling for medication use, body mass index, alcohol or illicit substance use did not affect the results.

CONCLUSION

In this large sample of patients with schizophrenia- and bipolar spectrum disorders, we found no associations between cholesterol levels and aggression or impulsivity. This has clinical implications as patients with SMD are at increased CVD risk and currently undertreated with statins.

Low total cholesterol and low-density lipoprotein associated with aggression and hostility in recent suicide attempters

Low cholesterol levels have been correlated with both suicidal and aggressive behavior in psychiatric patients. Few studies have investigated associations between serum lipid profiles and both aggressive state and trait. Fifty-two psychiatric medication-free inpatients were included in this study after a suicide attempt. Composite scores of "State Aggression" and "Trait Aggression" were calculated using relevant items from the Comprehensive Psychopathological Rating Scale and the Karolinska Scales of Personality. State Aggression was significantly and negatively correlated with total cholesterol (TC) and low-density lipoprotein (LDL). Trait Aggression was also significantly and negatively correlated with LDL, but not TC. There were small but significant mediation effects of severity of anxiety symptoms on the relationship between State Aggression and TC as well as LDL. In exploratory analyses we found that low cholesterol was also associated with personality traits of hostility. Moreover, low cholesterol was more robustly associated with personality trait items related to interpersonal aggression, as opposed to items related to irritability or more indirect, non-overt aggression. Our findings suggest that low cholesterol is associated with both state and trait aggression in suicide attempters. Future mechanistic studies are warranted to better understand the relationship between low cholesterol and high aggression in suicide attempters.

Objective predictors of outcome in forensic mental health services-a systematic review

This systematic review aimed to examine whether neurobiological methods, or other methods independent of clinical judgment, have been investigated to assist decision making in forensic mental health services and, if so, whether this may be a useful strategy for predicting outcomes. OVID-Medline, Embase, and PsychInfo (inception-January 2015) were searched, limiting to English and human studies, using terms relating to "predict," "outcome," "psychiatry," and "forensic" to identify primary research articles reporting on predictors of outcome in forensic mental health services not reliant on clinical judgment/self-report. Fifty studies investigating demographic, neuropsychological/neurophysiological, and biological predictors were identified, reporting on 3 broad outcomes: (i) inpatient violence, (ii) length of stay, (iii) reoffending. Factors associated positively, negatively, and showing no relationship with each outcome were extracted and compiled across studies. Of various demographic predictors examined, the most consistent associations were between previous psychiatric admissions and inpatient violence; a more "severe" offense and a longer length of stay; and young age and reoffending. Poor performance on tests of cognitive control and social cognition predicted inpatient violence while a neurophysiological measure of impulsivity showed utility predicting reoffending. Serum cholesterol and creatine kinase emerged as biological factors with potential to predict future inpatient violence. Research in this field is in its infancy, but investigations conducted to date indicate that using objective markers is a promising strategy to predict clinically significant outcomes.

Statins use and risk of depression: a systematic review and meta-analysis

IMPORTANCE

Statin use has been associated with depression; however studies of the association between statin use and depression have yielded mixed results.

OBJECTIVE

To determine whether statin use is associated with depression and to evaluate the evidence supporting this association.

DATA SOURCES

Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, EMBASE, PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were searched through December 28, 2012.

STUDY SELECTION

We included studies that evaluated exposure to statins, reported the development of depression, and relative risks or odds ratios (ORs) or provided data for their estimation. Two reviewers screened 981 abstracts independently using a standardized form, reviewed full text of 59 selected articles, and included 7 studies in this metaanalysis.

DATA EXTRACTION AND SYNTHESIS

Study design, statin exposure, development of depression, and study quality were extracted by 2 independent reviewers. A pooled OR with 95% confidence interval (CI) was estimated using the random-effects model and heterogeneity was assessed using Cochran's Q test and the I(2) statistic.

RESULTS

Seven observational studies (4 cohort, 2 nested case-control, and 1 cross-sectional) from 5 countries enrolling 9187 patients were included. Statin users were 32% less likely to develop depression than nonusers (adjusted OR, 0.68; 95% CI, 0.52-0.89). Modest heterogeneity was observed between the studies (I(2)=55%, P=0.01), which could be accounted for by one study, exclusion of which removed the heterogeneity (P=0.40, I(2)=2%) and further strengthened the antidepressant effect of statin (adjusted OR, 0.63; 95% CI, 0.43-0.93). Heterogeneity could not be explained by study design or study population. The quality of supporting evidence was fair.

CONCLUSIONS AND RELEVANCE

This systematic review and meta-analysis suggests that statin use is associated with lower risk for depression. However, higher-quality studies are needed to confirm the magnitude of this association.

Associations between aggressive behaviour scores and cardiovascular risk factors in childhood

OBJECTIVE

To examine the influence of aggressive behaviour scores on cardiovascular disease (CVD) risk factors throughout childhood.

METHODS

This study utilized cross-sectional and longitudinal data from the Western Australian Pregnancy Cohort (Raine) Study (n = 2900). Aggressive behaviour scores were derived from the Child Behavior Checklist/4-18(CBCL), Youth Self-Report/11-18 (YSR) and Teacher Report Form/6-18 (TRF). CVD risk factors included body mass index (BMI), blood pressure, fasting lipids and homeostasis model of insulin resistance (HOMA-IR).

RESULTS

Girls with higher aggressive behaviour scores had higher BMI from 10 years of age (P ≤ 0.001), higher BMI trajectories throughout childhood (P = 0.0003) and at 14 years higher HOMA-IR (P = 0.008). At the 14-year survey, this equated to a difference of 1.7 kg/m2 in the predicted BMI between the extreme CBCL scores in girls (top 5% (CBCL ≥ 17) vs. CBCL score = 0). Boys with higher aggressive behaviour scores had higher BMI at 5 years (P = 0.002), lower diastolic pressure at 14 years (P = 0.002) and lower systolic blood pressure trajectories throughout childhood (P = 0.016).

CONCLUSION

Aggressive behaviour influences BMI from early childhood in girls but not boys. If this association is causal, childhood offers the opportunity for early behavioural intervention for obesity prevention.

First-degree relatives with behavioural adverse effects on statins

Irritability, aggression and other adverse behavioural effects have been associated with the use of statins (3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors) and other drug classes. A number of studies have also linked low cholesterol with aggression and violence. This paper presents the cases of two first-degree male relative patients (father and son) identified by self-referral to the University of California in San Diego Statin Effects Study. Both patients experienced behavioural adverse effects on statins including irritability and aggression, however neither patient recognised a significant change in their behaviour. This may be the first report of behavioural adverse effects manifested on statins by first-degree male relatives, which may suggest possible familial/biological predisposition. These cases also highlight the issue of externalisation by patients of the origin of interpersonal discord, which may serve as an obstacle to adverse effects reporting and lead to negative outcomes for patients, and for those around them.

Thrombocyte serotonin and serum cholesterol concentration in suicidal and non-suicidal depressed patients

INTRODUCTION

Numerous studies have confirmed the connection of reduced serum cholesterol and thrombocyte serotonin concentration with suicidal behavior in psychiatric patients. The purpose of such studies was to determine the link among cholesterol and serotonin concentration, comparing depressed patients with and without attempted suicide with phenotypically healthy control group.

MATERIALS AND METHODS

The examinees' groups consisted of 55 depressed patients with suicide attempt and 77 depressed patients with no suicide attempt. In accordance to ICD-10, the above patients were separated in two subgroups; F32.2 and F33.2. Phenotypically healthy control group was presented by the group of healthy blood donors. The fasting serum cholesterol concentration was established using standard enzymatic method, while the thrombocyte serotonin concentration was determined by the enzymatic immune-chemical method (ELISA).

RESULTS

The ANOVA test (N=228, F(ratio)=8.26, p<0.001) found significant difference of cholesterol concentration between groups, with lowest concentration in depressed patients with attempted suicide (SNK post hoc test, p<0.05). Upon gender stratification, the significance remained for the female patients (ANOVA, N=125, F(ratio)=6.06, p=0.003). The serum cholesterol was shown to be statistically lower in the group of depressed patients with attempted suicide, diagnoses F32.2 (p=0.031) and F33.2 (p=0.011), compared to the group of depressed patients without attempted suicides. The thrombocyte serotonin was found to be significantly different in all examined groups, with the lowest thrombocyte serotonin in the group of depressed patients with no suicide attempt (SNK post hoc test, p<0.05, N=187, F(ratio)=37.69, p<0.001). The same significance was found for the group of female (ANOVA, N=103, F(ratio)=11.81, p<0.001) and the group of male patients (ANOVA, N=84, F(ratio)=30.40, p<0.001). The thrombocyte serotonin was significantly lower in the group of depressed patients with no suicide attempt (F32.2), compared to the same diagnosis in the group of depressed patients with suicide attempt (MW-test, p=0.018).

CONCLUSION

In the group of depressed patients with attempted suicide, statistically significant lower serum cholesterol values have been confirmed. In the group of depressed patients with no suicide attempt, statistically significant lower values of thrombocyte serotonin have been confirmed, presumably as the response to the psychopharmacological therapy.

Lipid-lowering medication use and aggression scores in women: a report from the NHLBI-sponsored WISE study

AIM

The aim of this study was to examine the association between the use of lipid-lowering medication and aggressive responding, hostility, cynicism, and depression scores in women undergoing coronary angiography.

METHODS

The cohort included 498 women from the National Heart, Lung and Blood Institute (NHLBI)-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. WISE is a four-center study of women with chest pain who underwent quantitative coronary angiography for suspected myocardial ischemia. The psychosocial indices included the Cook Medley Hostility questionnaire, measuring aggression, hostility, and cynicism, and the Beck Depression Inventory (BDI).

RESULTS

Compared to those not on lipid-lowering medication, women receiving lipid-lowering pharmacotherapy were older (62 vs. 55 years, p < 0.001) and had more hypertension, dyslipidemia, diabetes, and coronary artery disease (CAD, defined as > or =50% stenoses in at least one epicardial artery) (all p < 0.003). Women on lipid-lowering medication had higher aggressive responding scores than those not on medication, 3.0 +/- 1.8 vs. 2.7 +/- 1.7, respectively (age-adjusted p < 0.003). This association persisted after adjustment for coronary risk factors, education, and extent of angiographic disease (CAD) (p < 0.005), and after exclusion of women using psychotropic medications (p < 0.001). Hostility, cynicism, and depression scores did not differ by medication use.

Statin adverse effects : a review of the literature and evidence for a mitochondrial mechanism

HMG-CoA reductase inhibitors (statins) are a widely used class of drug, and like all medications, have potential for adverse effects (AEs). Here we review the statin AE literature, first focusing on muscle AEs as the most reported problem both in the literature and by patients. Evidence regarding the statin muscle AE mechanism, dose effect, drug interactions, and genetic predisposition is examined. We hypothesize, and provide evidence, that the demonstrated mitochondrial mechanisms for muscle AEs have implications to other nonmuscle AEs in patients treated with statins. In meta-analyses of randomized controlled trials (RCTs), muscle AEs are more frequent with statins than with placebo. A number of manifestations of muscle AEs have been reported, with rhabdomyolysis the most feared. AEs are dose dependent, and risk is amplified by drug interactions that functionally increase statin potency, often through inhibition of the cytochrome P450 3A4 system. An array of additional risk factors for statin AEs are those that amplify (or reflect) mitochondrial or metabolic vulnerability, such as metabolic syndrome factors, thyroid disease, and genetic mutations linked to mitochondrial dysfunction. Converging evidence supports a mitochondrial foundation for muscle AEs associated with statins, and both theoretical and empirical considerations suggest that mitochondrial dysfunction may also underlie many nonmuscle statin AEs. Evidence from RCTs and studies of other designs indicates existence of additional statin-associated AEs, such as cognitive loss, neuropathy, pancreatic and hepatic dysfunction, and sexual dysfunction. Physician awareness of statin AEs is reportedly low even for the AEs most widely reported by patients. Awareness and vigilance for AEs should be maintained to enable informed treatment decisions, treatment modification if appropriate, improved quality of patient care, and reduced patient morbidity.

ABCG1 gene variants in suicidal behavior and aggression-related traits

The ABCG1 transporter seems to be involved in human cholesterol and sterol homeostasis. As alterations in cholesterol homeostasis have been widely linked to aggression, violence and suicidal behavior, we considered ABCG1 as a candidate gene for these traits. We studied 5 gene variants of ABCG1 in a sample of 571 suicide attempters, healthy controls and suicide completers. We also analyzed the relation to aggression-related traits, assessed by STAXI and FAF. Regarding the genotypes, there was no association with completed or attempted suicide with the tested SNPs. Regarding alleles, only one SNP (rs1044317) showed a slight association with suicide attempters in comparison to the controls. Interestingly, rs225374 G allele carriers had higher scores on the STAXI subscales "State Anger" and "Anger Out", as well as on the FAF subscales "Spontaneous Aggression", "Irritability" and "Aggression". Carriers of the rs914189 G allele scored higher on the FAF subscales "Spontaneous Aggression", "Reactive Aggression" and "Aggression". Carriers of the rs1044317 G allele had lower scores for STAXI "Trait Anger" and "Trait Temperament", and higher scores for STAXI "Anger Control". Our results provide evidence that the ABCG1 may influence aggression-related traits. Given that these represent intermediate phenotypes of suicidal behavior, ABCG1 might also act on suicidal behavior through these traits. The observed associations warrant further replications.

A study of serum lipid profile and serum apolipoproteins A1 and B in Indian male violent criminal offenders

BACKGROUND

High cholesterol has been advanced as the most important factor in the development of coronary artery disease. Most panels have recommended population-wide dietary restrictions, yet a body of evolving data yields evidence of the hazards of low cholesterol, including links to aggression and hostility.

OBJECTIVES

The aim of this study was to compare the serum lipid profile and serum apolipoproteins A1 and B of men with a violent criminal record and men with no criminal history.

METHOD

Fasting blood samples were collected from 30 men with a known history of violent crime and 30 men with no criminal record. Serum lipid profile and serum apolipoproteins A1 and B were measured in each sample, and compared between the two groups.

RESULTS

The group with the violent criminal record showed significantly lower total cholesterol, lower LDL cholesterol, higher apolipoprotein A1 and lower apolipoprotein B compared with the control group.

CONCLUSION

Lower total cholesterol, lower LDL cholesterol, higher apolipoprotein A1 and lower apolipoprotein B could predispose to violence. Future research might explore the possibility that diets offered in prison could affect relevant pathways in lipid metabolism.

Serum cholesterol concentrations and non-physical aggression in healthy adults

Although physical aggression in humans and other primates appears to be negatively associated with total serum cholesterol (TSC) concentrations, the relationship between other forms of aggression and TSC is less clear. A plurality of studies have reported a positive association, some have reported no association, and a minority have reported a negative association. Some authors have speculated that the variability in findings is attributable to inconsistencies in the definitions and measurement of what has often been termed "verbal" aggression. Buss and Perry have developed the Aggression Questionnaire, a theoretically-derived and empirically validated self-report measure of aggression that breaks aggression into subcomponents. One hundred and seventy-one college students and university personnel were recruited to participate in a cholesterol screening health initiative and then invited to participate in a study of mood and cholesterol. They completed a Demographic Questionnaire, and the Aggression Questionnaire. Regression analyses with age and Body Mass Index (BMI) as covariates revealed that anger, hostility, and verbal aggression significantly predicted TSC. Physical aggression did not. This finding suggests that non-physical forms of aggression may constitute a risk factor for coronary artery disease and one that may be worthy of targeting through behavioral interventions such as anger management training.

Prediction of inpatient violence

OBJECTIVE

An overview of studies on predictors and on the accuracy of prediction of inpatient violence should be given.

METHOD

To date, the published data do not allow a systematic meta-analysis due to different sample characteristics, different measures and definitions of violence, and different time frames of observation. Published studies were reviewed regarding significant predictors of inpatient violence.

RESULTS

Predictors of violence in institutional settings are different from predictors of violence in the community: variables such as sex, age, diagnosis and alcohol abuse play a minor role, while clinical and psychopathological variables are prominent. Only history of violence is a robust static predictor. The total level of positive and general psychotic symptoms seems to enhance the violence risk of inpatients, whereas results concerning specific features like delusions or command hallucinations are contradictory due to inevitable problems of sample selection. The accuracy of clinical predictions is better than chance but limited by the effects of therapeutic interventions and research artefacts.

CONCLUSION

The author argues that more precise determinations of the violence risk in institutions will fail and that the role of environmental factors has often been underestimated.

Severe irritability associated with statin cholesterol-lowering drugs

BACKGROUND

As use of a drug becomes widespread, the full spectrum of its effects becomes clearer. Although a link has been suggested between low or lowered cholesterol and irritability/aggression, less is known about possible links between irritability and statins.

AIM

To assess the possible connection of statin usage to severe irritability.

DESIGN

Case series.

METHODS

Six patients referred or self-referred with irritability and short temper on statin cholesterol-lowering drugs completed a survey providing information on character of behavioural effect, time-course of onset and recovery, and factors relevant to drug adverse effect causality.

RESULTS

In each case the personality disruption, once evident, was sustained until statin use was discontinued; and resolved promptly with drug cessation. In four patients, re-challenge with statins occurred, and led to recrudescence of the problem. All patients experienced other recognized statin adverse effects while on the drug. Manifestations of severe irritability included homicidal impulses, threats to others, road rage, generation of fear in family members, and damage to property.

DISCUSSION

Case series invariably raise more questions than they can answer. These case reports suggest that severe irritability may occur in some statin users. Although this adverse effect may be rare, potentially life-threatening adverse effects of drugs must be taken seriously.

Conceptual foundations of the UCSD Statin Study: a randomized controlled trial assessing the impact of statins on cognition, behavior, and biochemistry

BACKGROUND

Statin cholesterol-lowering drugs are among the most prescribed drugs in the United States. Their cardiac benefits are substantial and well supported. However, there has been persistent controversy regarding possible favorable or adverse effects of statins or of cholesterol reduction on cognition, mood, and behavior (including aggressive or violent behavior).

METHODS

The literature pertaining to the relationship of cholesterol or statins to several noncardiac domains was reviewed, including the link between statins (or cholesterol) and cognition, aggression, and serotonin.

RESULTS

There are reasons to think both favorable and adverse effects of statins and low cholesterol on cognition may pertain; the balance of these factors requires further elucidation. A substantial body of literature links low cholesterol level to aggressive behavior; statin randomized trials have not supported a connection, but they have not been designed to address this issue. A limited number of reports suggest a connection between reduced cholesterol level and reduced serotonin level, but more information is needed with serotonin measures that are practical for clinical use. Whether lipophilic and hydrophilic statins differ in their impact should be assessed.

CONCLUSION

There is a strong need for randomized controlled trial data to more clearly establish the impact of hydrophilic and lipophilic statins on cognition, aggression, and serotonin, as well as on other measures relevant to risks and quality-of-life impact in noncardiac domains.

Minor thalassemia may be a risk factor for impulsiveness

Frequent studies have demonstrated the relationship between low cholesterol levels and increased aggression as well as suicide. In primates, cholesterol reduction has been linked to increased behavioral acts of aggression. Patients with low cholesterol show hypersensitivity in the detection of anger and sadness. It is documented that minor thalassemics have lower serum cholesterol levels than the general population. Therefore, it could be postulated that minor thalassemics may be predisposed to impulsiveness due to the decrement of serum cholesterol levels.

Association between low plasma levels of cholesterol and relapse in cocaine addicts

OBJECTIVE

In light of recent studies suggesting the existence of associations between low concentrations of cholesterol and various psychiatric disorders, we decided to explore relationships between cholesterol levels and relapse rates in a group of cocaine addicts who had undergone inpatient detoxification.

METHODS

The total cholesterol levels of 38 non-opiate-dependent and non-alcohol-dependent cocaine addicts were determined while they were hospitalized. Drug use was subsequently assessed 3, 6, and 12 months after patients were discharged from the hospital.

RESULTS

Comparisons of the cholesterol levels (obtained during hospitalization) of relapsers and nonrelapsers by analyses of covariance with age and weight as covariates revealed significantly lower cholesterol values in patients who relapsed at 3 months (p =.046), 6 months (p =.030), and 12 months (p =.019) after discharge.

CONCLUSIONS

This study showed an association between a low total cholesterol level and relapse rates in detoxified cocaine addicts. Reasons for the predictive value of low cholesterol levels for relapse for up to 1 year after cholesterol measurements were made are unclear. These data are preliminary and in need of replication.

Relationship between attempted suicide, serum cholesterol level and novelty seeking in psychiatric in-patients

This study sought to compare the serum cholesterol levels of psychiatric in-patients, with and without recent suicidal behavior. The hypothesis was that the temperament dimension novelty seeking (NS) would be an intermediary variable, correlated with both serum cholesterol level and suicidal behavior. The study included 155 psychiatric in-patients, 21.9% (n=34) of whom had recently attempted suicide. Their cholesterol level was compared to that of patients with no suicide attempt. The NS dimension was explored with the aid of Cloninger's Temperament and Character Inventory. Significantly lower average cholesterol levels were found in women who had attempted suicide before hospitalization than for the others (4.71 mmol/l+/-0.83 vs. 5.52 mmol/l+/-1.36). Similar results were not found for men. However, the average NS scores did not differ according to suicide attempts in women or in men, and the scores of NS were not correlated with cholesterol level. This study confirms an association between low cholesterol and suicidal behavior in women only, but this association seems independent from the NS personality dimension. The absence of a correlation between serum cholesterol levels and suicidal behavior in men could be linked to the small number of men included in the study.

Correlation between serum lipid concentrations and psychological distress

This study examines the correlations between serum lipid levels and psychological distress. There were 4444 consecutive attendees of general health clinics who participated in the study. Psychological symptoms were measured by the Taiwanese version of the Symptoms Check List 90, revised (T-SCL-90-R). Levels of fasting serum lipids, including total cholesterol, total triglycerides and high-density lipoprotein cholesterol (HDL-C), were determined. Multiple linear regression analyses, with adjustment for confounders, revealed that the concentration of HDL-C had significant inverse associations with scores of depression, somatization and phobic anxiety. Women with an HDL-C level lower than 35 mg/dl scored significantly higher on depression, interpersonal sensitivity, phobia, anxiety, somatization and aggressive hostility, while subjects with a total cholesterol concentration lower than 160 mg/dl scored significantly higher on anxiety, aggressive hostility, phobia, and psychoticism. This study provides, for the first time, comprehensive data derived from the Taiwanese population on the link between lipids and psychological symptoms, revealing a reverse correlation between depression and serum concentrations of HDL-C.

Cholesterol reduction and non-illness mortality: meta-analysis of randomised clinical trials

OBJECTIVE

To investigate the association between cholesterol lowering interventions and risk of death from suicide, accident, or trauma (non-illness mortality).

DESIGN

Meta-analysis of the non-illness mortality outcomes of large, randomised clinical trials of cholesterol lowering treatments.

STUDIES REVIEWED

19 out of 21 eligible trials that had data available on non-illness mortality. INTERVENTIONS REVIEWED: Dietary modification, drug treatment, or partial ileal bypass surgery for 1-10 years.

MAIN OUTCOME MEASURE

Deaths from suicides, accidents, and violence in treatment groups compared with control groups.

RESULTS

Across all trials, the odds ratio of non-illness mortality in the treated groups, relative to control groups, was 1.18 (95% confidence interval 0.91 to 1.52; P=0.20). The odds ratios were 1.28 (0.94 to 1.74; P=0.12) for primary prevention trials and 1.00 (0.65 to 1.55; P=0.98) for secondary prevention trials. Randomised clinical trials using statins did not show a treatment related rise in non-illness mortality (0.84, 0.50 to 1.41; P=0.50), whereas a trend toward increased deaths from suicide and violence was observed in trials of dietary interventions and non-statin drugs (1.32, 0.98 to 1.77; P=0.06). No relation was found between the magnitude of cholesterol reduction and non-illness mortality (P=0.23).

CONCLUSION

Currently available evidence does not indicate that non-illness mortality is increased significantly by cholesterol lowering treatments. A modest increase may occur with dietary interventions and non-statin drugs.

Serum cholesterol concentrations and mood states in violent psychiatric patients: an experience sampling study

The well-documented negative association between serum cholesterol and aggressive behavior has led Kaplan to propose a cholesterol-serotonin hypothesis of aggression. According to this hypothesis, low dietary cholesterol intake leads to depressed central serotonergic activity, which itself has been reported in numerous studies of violent individuals. In the present study, 25 violent psychiatric patients participated in a microbehavioral experience sampling procedure to examine differences in self-reports of affective and cognitive experiences as a function of serum cholesterol concentrations. For 7 days, they wore signaling devices that emitted an average of seven signals a day. Following each signal, patients filled out a mood questionnaire. Total serum cholesterol (TSC) concentration was positively associated with measures of affect, cognitive efficiency, activation, and sociability, suggesting a link between low TSC and dysphoria. These findings are consistent with the cholesterol-serotonin hypothesis and with the substantive literature linking both aggression and depression to depressed central serotonergic activity.

Low cholesterol and violent crime

BACKGROUND

Community cohort studies and meta-analyses of randomized trials have shown a relation between low or lowered cholesterol and death by violence (homicide, suicide, accident); in primates, cholesterol reduction has been linked to increased behavioral acts of aggression (Kaplan J, Manuck S. The effects of fat and cholesterol on aggressive behaviour in monkeys. Psychosom. Med 1990;52:226-7; Kaplan J, Shively C, Fontenot D, Morgan T, Howell S, Manuck S et al. Demonstration of an association among dietary cholesterol, central serotonergic activity, and social behaviour in monkeys. Psychosom. Med 1994;56:479-84.). In this study we test for the first time whether cholesterol level is related to commission of violent crimes against others in a large community cohort.

METHODS

We merged one-time cholesterol measurements on 79,777 subjects enrolled in a health screening project in Varmland, Sweden with subsequent police records for arrests for violent crimes in men and women aged 24-70 at enrollment; and with information on covariates. We performed a nested case control comparison of cholesterol in violent criminals - defined as those with two or more crimes of violence against others - to cholesterol in nonoffenders matched on age, enrollment year, sex, education and alcohol, using variable-ratio matching, with a nonparametric sign test.

RESULTS

One hundred individuals met criteria for criminal violence. Low cholesterol (below the median) was strongly associated with criminal violence in unadjusted analysis (Men: risk ratio 1.94, P=0.002; all subjects risk ratio 2.32, P<0.001). Age emerged as a strong confounder. Adjusting for covariates using a matching procedure, violent criminals had significantly lower cholesterol than others identical in age, sex, alcohol indices and education, using a nonparametric sign test (P=0.012 all subjects; P=0.035 men).

CONCLUSIONS

Adjusting for other factors, low cholesterol is associated with increased subsequent criminal violence.

Effects of lovastatin on cognitive function and psychological well-being

PURPOSE

Animal research and cross-sectional studies suggest that serum lipid concentrations may influence cognitive function, mood, and behavior, but few clinical trials have studied these effects.

SUBJECTS AND METHODS

In this double-blind investigation, 209 generally healthy adults with a serum low-density-lipoprotein (LDL) cholesterol level of 160 mg/dL or higher were randomly assigned to 6-month treatment with lovastatin (20 mg) or placebo. Assessments of neuropsychological performance, depression, hostility, and quality of life were conducted at baseline and at the end of the treatment period. Summary effect sizes were estimated as z scores on a standard deviation (SD) scale.

RESULTS

Placebo-treated subjects improved between baseline and posttreatment periods on neuropsychological tests in all five performance domains, consistent with the effects of practice on test performance (all P <0.04), whereas those treated with lovastatin improved only on tests of memory recall (P = 0.03). Comparisons of the changes in performance between placebo- and lovastatin-treated subjects revealed small, but statistically significant, differences for tests of attention (z score = 0.18; 95% confidence interval (CI), 0.06 to 0.31; P = 0.005) and psychomotor speed (z score = 0.17; 95% CI, 0.05 to 0.28; P = 0. 004) that were consistent with greater improvement in the placebo group. Psychological well-being, as measured several ways, was not affected by lovastatin.

CONCLUSION

Treatment of hypercholesterolemia with lovastatin did not cause psychological distress or substantially alter cognitive function. Treatment did result in small performance decrements on neuropsychological tests of attention and psychomotor speed, the clinical importance of which is uncertain.

No correlation of serum cholesterol levels with measures of violence in patients with schizophrenia and non-psychotic disorders

Epidemiological studies, animal studies, and clinical studies yielded conflicting results concerning a supposed association between increased risk for suicide and violence, and low serum cholesterol levels. Until now, no data has been available for patients with schizophrenia, a disorder with a well-known increased risk of violence. Correlations of serum cholesterol levels at admission and measures of violence were investigated in 103 consecutively admitted patients (44 males, 59 females) of a general psychiatric admission unit. Seventy subjects were diagnosed as suffering from schizophrenia or schizoaffective disorder (ICD-10 F 20, F25), and 33 were diagnosed as suffering from non-psychotic disorders (mainly personality disorders). The level of total exhibited violence during the inpatient treatment period was measured in each patient by the Modified Overt Aggression Scale (MOAS), the Social Dysfunction and Aggression Scale (SDAS), the Staff Observation Aggression Scale (SOAS), and the Violence Scale (VS). Correlations of all violence measures were high (0.75-0.90), but no correlation was found with cholesterol levels, neither for psychotic nor for non-psychotic subjects, neither for men nor for women. The hypothesis of associations of violence and cholesterol levels is not supported by the data.

Serum cholesterol, suicidal tendencies, impulsivity, aggression, and depression in adolescent psychiatric inpatients

BACKGROUND

This study was undertaken to examine the relationship between serum cholesterol levels and suicidal behaviors in adolescent psychiatric inpatients. Any association between serum cholesterol and measures of suicidal behavior, impulsivity, aggression, anxiety, and depression was also examined.

METHODS

Consecutive admissions (n = 152) to an adolescent psychiatric inpatient unit were assessed using measures of suicidal behavior, violence, impulsivity, and depression. Serum cholesterol was compared between those admitted for reasons of suicidal tendencies and those for other reasons. Correlation between serum cholesterol and measures of suicidal behavior, violence, impulsivity, and depression were examined.

RESULTS

Serum cholesterol levels were significantly higher in adolescent patients who were currently suicidal than in nonsuicidal adolescents. Within the suicidal group, but not in the total inpatient group, serum cholesterol correlated negatively with the degree of suicidal behavior. No correlation between serum cholesterol levels and depression, violence, and impulsivity were detected. No significant differences were found in serum cholesterol levels between diagnoses or between suicidal and nonsuicidal patients within each diagnostic group.

CONCLUSIONS

The association between cholesterol and suicidal tendencies remains complex and may depend on several variables within the population studied. Its usefulness as a biologic risk factor in clinical samples remains to be determined.

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.

Cholesterol and mental disorder

BACKGROUND

Cholesterol plays an important part in cellular structure and function and changes in serum levels may affect neurotransmission in the central nervous system.

METHOD

A MEDLINE literature search was made covering the period 1990-95 with systematic searching of citations from the articles identified. Representative articles were selected, focusing on those aspects which had not been thoroughly reviewed elsewhere, namely suicidal ideation, depression, personality and schizophrenia.

RESULTS

Lowering cholesterol levels have been associated with an increase in violent deaths in cardiovascular primary prevention studies. However, altered cholesterol levels have also been reported in relation to other psychiatric disorders.

CONCLUSION

There is substantial evidence that serum cholesterol levels may be associated with variations in mental state or personality. Further work is needed to clarify this and to elucidate the mechanisms involved.

Is there an association among low untreated serum lipid levels, anger, and hazardous driving?

Anger and hazardous driving were explored in two studies for their possible explanatory role in the low cholesterol-violent mortality association. In Study 1, we obtained fasting blood samples and indices of anger and driving habits from 102 healthy young adults. Among men (but not women), lower low-density lipoprotein (LDL) cholesterol levels were associated with significantly higher anger (r = 41, p < .01) and unsafe driving habits (r = -.30, p < .05), and although total cholesterol levels were correlated in the predicted direction, these were not significant. In Study 2, 78 healthy young men completed the same measures, and this time, both lower total and LDL-cholesterol were significantly related to increased anger and dangerous driving. Implications of these findings are discussed as are possible avenues for future research. Further scrutiny of the components of serum cholesterol and their relation to psychological factors may aid us in better understanding the reasons why men are at increased risk for hazardous behavior and violent death.

Serum cholesterol and perception of anger and sadness

Analysis of cholesterol levels in 34 forensic patients indicated significant associations with measures of the patients' perceptions of the emotional content in auditory stimuli. In particular, patients with low cholesterol showed hypersensitivity in the detection of anger and sadness. The authors hypothesize the involvement of serotonin in the hypersensitivity effects. Organicity and age were ruled out as contributing factors.

Aggressiveness, dominance, developmental factors, and serum cholesterol level in college males

The present study was conducted to examine for college males relations between aggressiveness (or expressive hostility) and dominance and (a) particular developmental experiences and (b) total serum cholesterol. Aggressiveness but not dominance was found to be positively related to subjects' reports of their parents' behavior which reflected (a) less genuine acceptance, (b) more interference in the person's desires as a child, and (c) more punitiveness. For low-physically fit subjects, both aggressiveness and dominance were found to be positively related to levels of total serum cholesterol. These relations are congruent with the notion that both aggressiveness and dominance may contribute to hastening coronary atherosclerosis and risk of CHD via elevated levels of plasma lipids. It should be noted, however, that the relations obtained in the present study were all modest in size. For high-physically fit individuals associations were not found between total serum cholesterol and either aggressiveness or dominance. These results suggest that good physical fitness may attenuate the degree to which either aggressiveness or dominance may adversely affect health via elevated levels of cholesterol.