Statin treatment and the risk of depression

Association of statin use with risk of depression and anxiety: A prospective large cohort study

OBJECTIVES

To examine associations between regular statin use and the incidence of depression and anxiety.

METHODS

This cohort was based on UK Biobank participants without depression/anxiety recruited between 2006 and 2010. The self-reported regular statin use was collected at baseline. Depression and anxiety outcomes were assessed by diagnostic interviews (international classification of diseases codes) and nondiagnostic scales (mental well-being questionnaires). Cox proportional hazards models adjusted for a wide range of confounders were used to estimate associations of statins with incident depression/anxiety.

RESULTS

Among 363,551 eligible participants, 55,838 reported regular statin use. During a 13-year follow-up, 14,765 cases of depression and 15,494 cases of anxiety were identified. Compared with non-statin users, statin use was associated with reduced risk of depression (hazard ratio [HR]: 0.87; 95% confidence interval [CI]: 0.81, 0.94) and anxiety (HR: 0.90, 95% CI: 0.84, 0.97). Effects of statins on depression were consistent in sensitivity analyses and may be less influenced by unmeasured confounders. However, results of online survey data showed that statin use might not be associated with incident anxiety (HR: 0.96, 95% CI: 0.85, 1.09).

CONCLUSION

Regular statin use was associated with a lower risk of depression. No clear associations between statin use and anxiety were found.

"Inflamed" depression: A review of the interactions between depression and inflammation and current anti-inflammatory strategies for depression

Depression is a common mental disorder, the effective treatment of which remains a challenging issue worldwide. The clinical pathogenesis of depression has been deeply explored, leading to the formulation of various pathogenic hypotheses. Among these, the monoamine neurotransmitter hypothesis holds a prominent position, yet it has significant limitations as more than one-third of patients do not respond to conventional treatments targeting monoamine transmission disturbances. Over the past few decades, a growing body of research has highlighted the link between inflammation and depression as a potential key factor in the pathophysiology of depression. In this review, we first summarize the relationship between inflammation and depression, with a focus on the pathophysiological changes mediated by inflammation in depression. The mechanisms linking inflammation to depression as well as multiple anti-inflammatory strategies are also discussed, and their efficacy and safety are assessed. This review broadens the perspective on specific aspects of using anti-inflammatory strategies for treating depression, laying the groundwork for advancing precision medicine for individuals suffering from "inflamed" depression.

The association between statin use and depression in diabetes

BACKGROUND

Depression is a common mental disorder. Some studies have demonstrated that people with diabetes are more likely to suffer from depression. Statins are an everyday use for diabetes. Trials of statin therapy have had conflicting findings on the potential risk of depression.

METHODS

The National Health and Nutrition Examination Survey (NHANES) 2005-2018 was used to collect a representative sample. Weighted multivariate logistic regression models were used to evaluate odds ratios (ORs) and 95 % CIs for having depression symptoms. We performed stratified analyses to compare the effects of statins in subsamples with and without diabetes on depression symptoms.

RESULTS

Statin use showed a significant and strong decreasing effect on having depression symptoms in participants with diabetes (aOR (adjusted OR) 0.59, p = 0.014) compared with that in non-diabetics (aOR 0.78, p = 0.128). Diabetic individuals with statin use for >5 years had a lower risk of having depression symptoms (aOR 0.42, p = 0.002) than those with shorter-term statin use (1-5 years, aOR 0.69, p = 0.111; <1 year: aOR 0.83, p = 0.646). Atorvastatin was more effective in decreasing depression symptoms either in diabetes (aOR 0.49, p = 0.018) or in non-diabetes (aOR 0.58, p = 0.033).

LIMITATIONS

First, the dosage of statins cannot be obtained from NHANES datasets. Second, after being stratified, the number of participants for several statins was insufficient. Third, recall bias may exist in the survey.

CONCLUSIONS

Diabetics with depression symptoms may benefit from long-term statin therapy. Atorvastatin and pravastatin should be recommended for diabetic patients with depression.

Pathophysiological mechanisms of post-myocardial infarction depression: a narrative review

Myocardial infarction (MI) can have significant physical and mental consequences. Depression is a prevalent psychiatric condition after MI which can reduce the quality of life and increase the mortality rates of patients. However, the connection between MI and depression has remained under-appreciated. This review examines the potential connection between depression and MI by overviewing the possible pathophysiologic mechanisms including dysregulation of the hypothalamic-pituitary-adrenal axis and autonomic nervous system, coagulation system dysfunction, inflammation, environmental factors, as well as, genetic factors. Furthermore, depression can be an adverse event of medications used for MI treatment including beta-blockers, statins, or anti-platelet agents. The need for early detection and management of depression in patients with MI is, therefore, crucial for improving their overall prognosis. Adherence to treatments and regular follow-up visits can ensure the best response to treatment.

Investigating the potential anti-depressive mechanisms of statins: a transcriptomic and Mendelian randomization analysis

Observational studies and randomized controlled trials presented inconsistent findings on the effects of cholesterol-lowering statins on depression. It therefore remains unclear whether statins have any beneficial effects on depression, and if so, what the underlying molecular mechanisms are. Here, we aimed to use genomic approaches to investigate this further. Using Connectivity Map (CMap), we first investigated whether statins and antidepressants shared pharmacological effects by interrogating gene expression responses to drug exposure in human cell lines. Second, using Mendelian randomization analysis, we investigated both on-target (through HMGCR inhibition) and potential off-target (through ITGAL and HDAC2 inhibition) causal effects of statins on depression risk and depressive symptoms, and traits related to the shared biological pathways identified from CMap analysis. Compounds inducing highly similar gene expression responses to statins in HA1E cells (indicated by an average connectivity score with statins > 90) were found to be enriched for antidepressants (12 out of 38 antidepressants; p = 9E-08). Genes perturbed in the same direction by both statins and antidepressants were significantly enriched for diverse cellular and metabolic pathways, and various immune activation, development and response processes. MR analysis did not identify any significant associations between statin exposure and depression risk or symptoms after multiple testing correction. However, genetically proxied HMGCR inhibition was strongly associated with alterations in platelets (a prominent serotonin reservoir) and monocyte percentage, which have previously been implicated in depression. Genetically proxied ITGAL inhibition was strongly associated with basophil, monocyte and neutrophil counts. We identified biological pathways that are commonly perturbed by both statins and antidepressants, and haematological biomarkers genetically associated with statin targets. Our findings warrant pre-clinical investigation of the causal role of these shared pathways in depression and potential as therapeutic targets, and investigation of whether blood biomarkers may be important considerations in clinical trials investigating effects of statins on depression.

Association between statins and the risk of suicide attempt, depression, anxiety, and seizure: A population-based, self-controlled case series study

BACKGROUND

Risk of suicide attempt, depression, anxiety and seizure and the association with statins is an ongoing debate. We aim to investigate the association between statins and the above neuropsychological outcomes, in specific pre- and post-exposure time windows.

METHODS

We identified patients aged 40-75 years old who were dispensed a statin between January 1, 2003 and December 31, 2012 from the Hong Kong Clinical Data Analysis & Reporting System (CDARS), an electronic medical records database. Patients with new onset of suicide attempt, depression, anxiety and seizure were derived from the original dataset separately, in a self-controlled case series study design. A non-parametric spline-based self-controlled case series model was built to measure continuous changes of risk.

RESULTS

We identified 396,614 statin users. The risk of each outcome was elevated prior to statin initiation with incidence rate ratios of 1.38 (95 % CI, 1.09-1.74) for suicide attempt, 1.29 (95 % CI, 1.15-1.45) for depression, 1.35 (95 % CI, 1.19-1.53) for anxiety, and 1.45 (95 % CI, 1.21-1.73) for seizure. The incidence rate ratios remained elevated after the initiation of statins during the first 90 and 91-365 days after statin prescription and decreased to the baseline level after 1 year of continuous prescription.

LIMITATIONS

CDARS includes prescription data but not adherence data, which could lead to misclassification of exposure periods.

CONCLUSIONS

Our study does not support a direct association between statin use and suicide attempt, depression, anxiety and seizure, whose risks could be explained by cardiovascular events, for which statins were prescribed.

The Anti-Depressant Effects of Statins in Patients With Major Depression Post-Myocardial Infarction: An Updated Review 2022

Statins are the most commonly prescribed lipid-lowering agents in patients with cardiovascular disease, and more than half of the patients with cardiovascular disease have associated depressive symptoms, particularly post-myocardial infarction, which is a major trigger for depression. In our research, we tried to understand the anti-depressant effects of statins, the mechanisms, risks and benefits, and potential drug-drug interactions with anti-depressant medications. We reviewed all the relevant information from inception up to September 2022 regarding the anti-depressant effects of statins. The database used was PubMed, and the keywords were statins, major depression, post-myocardial infarction, and hydroxy methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors. We have screened each of the articles carefully, including both human and animal studies, and found a positive correlation between reduction in depressive symptoms with statin therapy as adjunctive treatment with conventional anti-depressants. In conclusion, statins as a monotherapy are not an effective treatment for depression post-myocardial infarction but are good add-on options along with standard therapy such as selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs). Statins are safe and have no serious drug-drug interactions with anti-depressants. We would like to encourage large-scale observational studies and further post-marketing surveillance to improve our knowledge regarding the effectiveness of statins in the treatment of depression.

Statins and Antidepressants: A Comprehensive Review and Clinical Outlook of the Risks and Benefits of Co-prescription (2022)

Antidepressants are the most prescribed medications in the United States, and the most frequently prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs) followed by serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), serotonin antagonist and reuptake inhibitors (SARIs), and norepinephrine-dopamine reuptake inhibitors (NDRI). On the other hand, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, also known as statins, are the most prescribed lipid-lowering medications, and because the majority of patients with cardiovascular disease (CVD) have depressive symptoms, it is essential to understand the possible drug-drug interactions these two classes of medications can have, their potential synergistic mechanisms, and possible risks. In our research, we tried to understand the facts and uncover any missing links regarding the potential risks and benefits of statins and antidepressant co-prescription in the current clinical scenario. We reviewed all the relevant information from inception up to October 2022 regarding the antidepressant and statin polypharmacy. The databases we used were PubMed and PubMed Central, and the 11 keywords were "statins," "SSRI," "SNRI," "selective serotonin reuptake inhibitors," "serotonin-norepinephrine reuptake inhibitors," "antidepressants," "HMG-CoA reductase inhibitors," "tricyclic antidepressants," "monoamine oxidase inhibitors," "serotonin antagonist and reuptake inhibitors," and "norepinephrine-dopamine reuptake inhibitors." We carefully screened each of the relevant articles, including animal and human studies. In our study, we concluded that co-prescription of statins and SSRIs/SNRIs was generally safe and should be encouraged due to the potential synergistic nature of their effects in patients with CVD and major depression, and caution is advised with all other classes of antidepressants. We would like to encourage the undertaking of large-scale observational studies and proactive postmarketing surveillance to improve our knowledge regarding this topic considering the immense clinical importance it holds by directly and indirectly affecting half the population worldwide.

Statins in depression: a repurposed medical treatment can provide novel insights in mental health

Depression has a large burden, but the development of new drugs for its treatment has proved difficult. Progresses in neuroscience have highlighted several physiopathological pathways, notably inflammatory and metabolic ones, likely involved in the genesis of depressive symptoms. A novel strategy proposes to repurpose established medical treatments of known safety and to investigate their potential antidepressant activity. Among numerous candidates, growing evidence suggests that statins may have a positive role in the treatment of depressive disorders, although some have raised concerns about possible depressogenic effects of these widely prescribed medications. This narrative review summarises relevant findings from translational studies implicating many interconnected neurobiological and neuropsychological, cardiovascular, endocrine-metabolic, and immunological mechanisms by which statins could influence mood. Also, the most recent clinical investigations on the effects of statins in depression are presented. Overall, the use of statins for the treatment of depressive symptoms cannot be recommended based on the available literature, though this might change as several larger, methodologically robust studies are being conducted. Nevertheless, statins can already be acknowledged as a driver of innovation in mental health, as they provide a novel perspective to the physical health of people with depression and for the development of more precise antidepressant treatments.

Effect of Statins on All-Cause Mortality in Adults: A Systematic Review and Meta-Analysis of Propensity Score-Matched Studies

Statins are lipid-lowering medications used for the prevention of cardiovascular disease (CVD), but the pleiotropic effects of statins might be beneficial in other chronic diseases. This meta-analysis investigated the association between statin use and mortality in different chronic conditions. Eligible studies were real-world studies that compared all-cause mortality over at least 12 months between propensity score-matched statin users and non-users. Overall, 54 studies were included: 21 in CVD, 6 in chronic kidney disease, 6 in chronic inflammatory diseases, 3 in cancer, and 18 in other diseases. The risk of all-cause mortality was significantly reduced in statin users (hazard ratio: 0.72, 95% confidence interval: 0.66−0.76). The reduction in mortality risk was similar in CVD studies (0.73, 0.66−0.76) and non-CVD studies (0.70, 0.67−0.79). There were no significant differences in the risk reduction between cohorts with different diseases (p = 0.179). The greatest mortality reduction was seen in studies from Asia (0.61, 0.61−0.73) and the lowest in studies from North America (0.78, 0.73−0.83) and Australia (0.78, 0.62−0.97). There was a significant heterogeneity (I2 = 95%, tau2 = 0.029, p < 0.01). In conclusion, statin use was associated with a significantly reduced risk of all-cause mortality in real-world cohorts with CVD and non-CVD.

Changes in regulators of lipid metabolism in the brain: a study of animal models of depression and hypothyroidism

Metabolic disturbances in the brain are assumed to be early changes involved in the pathogenesis of depression, and these alterations may be intensified by a deficiency of thyroid hormones. In contrast to glucose metabolism, the link between altered brain lipids and the pathogenesis of depression is poorly understood, therefore in the present study, we determine transcription factors and enzymes regulating cholesterol and fatty acid biosynthesis in the brain structures in an animal model of depression, hypothyroidism and the coexistence of these diseases.

In used model of depression, a decrease in the active form of the transcription factor SREBP-2 in the hippocampus was demonstrated, thus suggesting a reduction in cholesterol biosynthesis. In turn, in the hypothyroidism model, the reduction of cholesterol biosynthesis in the frontal cortex was demonstrated by both the reduction of mature SREBP-2 and the concentration of enzymes involved in cholesterol biosynthesis. The lower expression of LDL receptors in the frontal cortex indicates the restriction of cholesterol uptake into the cells in the model of coexistence of depression and hypothyroidism. Moreover, the identified changes in the levels of SNAP-25, GLP-1R and GLP-2R pointed to disturbances in synaptic plasticity and neuroprotection mechanisms in the examined brain structures.

In conclusion, a reduction in cholesterol synthesis in the hippocampus in the model of depression may be the reason for the reduction of synaptic plasticity, whereas a lower level of LDL-R occurring in the frontal cortex in rats from the model of depression and hypothyroidism coexistence could be the reason of anxiogenic and depression-like behaviors.

The association between leftover food consumption and depression among older adults: Findings from a cross-sectional study

BACKGROUND

Leftover food consumption is very prevalent among the Chinese older adults, however, the potential effects of leftover eating consumption on depression have not yet been investigated.

OBJECTIVES

The study aims to determine the association between leftover consumption on depression among older adults.

METHODS

Data of leftover consumption frequency was collected in a cross-sectional study with a provincial representative sample of 5992 older adults (aged 60 or older) in 2019. Depression symptoms were assessed by the 9-item screener Patient Health Questionnaire (PHQ-9). Multiple logistic regression models were applied to analyze the association of the frequency of leftover eating consumption and the presence and the severity of depression.

RESULTS

After controlling for all the covariates, the participants who consume leftover food everyday had higher risk of having depression symptom comparing to those who had the lowest frequency of leftover eating (OR: 1.675, 95% CI: 1.435-1.956, p < 0.001). The participants who consume leftover food every day was also associated with more severe depression symptoms (OR: 1.621, 95% CI: 1.397-1.881, p < 0.001), when comparing to the reference group. The associations seemed stronger in men than women.

LIMITATIONS

The causal relationship between leftover consumption behavior and depression could not be determined due to the cross-sectional design. Moreover, the variety or handling method of the leftover food was not specified.

CONCLUSION

Leftovers eating frequency was associated with the presence and severity of depression symptoms among older adults.

Update on Statin Treatment in Patients with Neuropsychiatric Disorders

Statins are widely accepted as first-choice agents for the prevention of lipid-related cardiovascular diseases. These drugs have both anti-inflammatory and anti-oxidant properties, which may also make them effective as potential treatment marked by perturbations in these pathways, such as some neuropsychiatric disorders. In this narrative review, we have investigated the effects of statin therapy in individuals suffering from major depressive disorder (MDD), schizophrenia, anxiety, obsessive-compulsive disorder (OCD), bipolar disorder (BD), delirium, and autism spectrum disorders using a broad online search of electronic databases. We also explored the adverse effects of these drugs to obtain insights into the benefits and risks associated with their use in the treatment of these disorders. Lipophilic statins (including simvastatin) because of better brain penetrance may have greater protective effects against MDD and schizophrenia. The significant positive effects of statins in the treatment of anxiety disorders without any serious adverse side effects were shown in numerous studies. In OCD, BD, and delirium, limitations, and contradictions in the available data make it difficult to draw conclusions on any positive effect of statins. The positive effects of simvastatin in autism disorders have been evaluated in only a small number of clinical trials. Although some studies showed positive effect of statins in some neuropsychiatric disorders, further prospective studies are needed to confirm this and define the most effective doses and treatment durations.

Statins in Depression: An Evidence-Based Overview of Mechanisms and Clinical Studies

Background: Depression is a leading cause of disability, burdened by high levels of non-response to conventional antidepressants. Novel therapeutic strategies targeting non-monoaminergic pathways are sorely needed. The widely available and safe statins have several putative mechanisms of action, especially anti-inflammatory, which make them ideal candidates for repurposing in the treatment of depression. A large number of articles has been published on this topic. The aim of this study is to assess this literature according to evidence-based medicine principles to inform clinical practise and research. Methods: We performed a systematic review of the electronic databases MEDLINE, CENTRAL, Web of Science, CINAHL, and ClinicalTrials.gov, and an unstructured Google Scholar and manual search, until the 9th of April 2021, for all types of clinical studies assessing the effects of statins in depression. Results: Seventy-two studies were retrieved that investigated the effects of statins on the risk of developing depression or on depressive symptoms in both depressed and non-depressed populations. Fifteen studies specifically addressed the effects of statins on inflammatory-related symptoms of anhedonia, psychomotor retardation, anxiety, and sleep disturbances in depression. Most studies suggested a positive effect of statins on the occurrence and severity of depression, with fewer studies showing no effect, while a minority indicated some negative effects. Limitations: We provide a narrative report on all the included studies but did not perform any quantitative analysis, which limits the strength of our conclusions. Conclusions: Robust evidence indicates that statins are unlikely to lead to depressive symptoms in the general population. Promising data suggest a potential role for statins in the treatment of depression. Further clinical studies are needed, especially in specific subgroups of patients identified by pre-treatment assessments of inflammatory and lipid profiles.

Statins: Neurobiological underpinnings and mechanisms in mood disorders

Statins (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors) treat dyslipidaemia and cardiovascular disease by inhibiting cholesterol biosynthesis. They also have immunomodulatory and anti-inflammatory properties. Beyond cardiovascular disease, cholesterol and inflammation appear to be components of the pathogenesis and pathophysiology of neuropsychiatric disorders. Statins may therefore afford some therapeutic benefit in mood disorders. In this paper, we review the pathophysiology of mood disorders with a focus on pharmacologically relevant pathways, using major depressive disorder and bipolar disorder as exemplars. Statins are discussed in the context of these disorders, with particular focus on the putative mechanisms involved in their anti-inflammatory and immunomodulatory effects. Recent clinical data suggest that statins may have antidepressant properties, however given their interactions with many known biological pathways, it has not been fully elucidated which of these are the major determinants of clinical outcomes in mood disorders. Moreover, it remains unclear what the appropriate dose, or appropriate patient phenotype for adjunctive treatment may be. High quality randomised control trials in concert with complementary biological investigations are needed if the potential clinical effects of statins on mood disorders, as well as their biological correlates, are to be better understood.

The association of depression with use of prescription drugs in adults with noncommunicable diseases: Based on NHANES in 2005-2016

BACKGROUND

It is not clear how the noncommunicable diseases (NCDs) performed in the association of depression with use of prescription drugs.

METHODS

This cross-sectional study involved 20,836 participants with at least one NCDs who aged over 20 years old in the National Health and Nutrition Examination Survey (NHANES) from 2005-2016. Ordinal logistic regression under complex sampling was used to examine the association of depression with use of prescription drugs in patients with different categories of NCDs.

RESULT

Among patients with respiratory diseases (OR: 1.41, 95% CI: 1.13-1.76), genitourinary diseases (OR: 1.59, 95% CI: 1.28-1.98), and cardiovascular diseases (OR: 1.43, 95% CI: 1.27-1.60), the risk of depression was higher among those who used prescription drugs than those who did not. The results showed that the association of depression with use of prescription drugs was significantly stronger, especially in patients with genitourinary diseases ≥65 years of age (OR: 1.91, 95% CI: 1.01-3.61). Trend analysis showed that the categories of prescription drugs used and the risk of depression was significantly statistically different (P for trend <0.001).

LIMITATIONS

Self-reported prevalence of depression may differ from actual prevalence of depression. The categories of NCDs studied in this article are limited and the association between specific drugs and depression is not analyzed.

CONCLUSIONS

In patients with NCDs, use of prescription drugs increased the risk of depression, and this risk increased significantly, especially in patients with genitourinary diseases who aged over 65 years. The risk of depression was increasing with the categories of prescription drugs used.

Statin use and depression risk: A systematic review and meta-analysis

BACKGROUND

Evidence regarding whether statin use is associated with depression is inconsistent. Therefore, we performed a meta-analysis to investigate this association.

METHODS

We searched PubMed, the Cochrane Library, and the EMBASE database, limiting the search to human patients and articles written in English and published by March 31, 2020. The Newcastle-Ottawa scale for observational studies was used to assess study quality. All included studies were evaluated by 2 reviewers independently; any discrepancies were resolved through discussion. Because of the heterogeneity of study populations, a random effects model was used to calculate the pooled effect size. Statistical heterogeneity across studies was assessed using the I² statistic. All analyses were performed using RevMan5 and Comprehensive Meta-Analysis software.

RESULTS

A total of 13 observational (9 cohort, 3 case-control, and 1 cross-sectional) studies conducted in 11 countries and enrolling 5 035 070 participants were included. Substantial statistical heterogeneity was discovered (I², 83%). Overall, use of statins was not associated with depression after trim and fill analysis (adjusted pooled odds ratio [OR], 0.87; 95% CI, 0.74-1.02). The finding was consistent in the subgroup analysis, except for studies published before 2013, showing statin use was associated with a lower risk of depression.

LIMITATIONS

High heterogeneity and asymmetry funnel plot of ORs from these studies were observed.

CONCLUSIONS

This meta-analysis revealed statin use was not associated with depression. However, high heterogeneity was observed between identified studies, and results were inconsistent in the subgroups of studies published before 2013.

Antidepressant drugs act by directly binding to TRKB neurotrophin receptors

It is unclear how binding of antidepressant drugs to their targets gives rise to the clinical antidepressant effect. We discovered that the transmembrane domain of tyrosine kinase receptor 2 (TRKB), the brain-derived neurotrophic factor (BDNF) receptor that promotes neuronal plasticity and antidepressant responses, has a cholesterol-sensing function that mediates synaptic effects of cholesterol. We then found that both typical and fast-acting antidepressants directly bind to TRKB, thereby facilitating synaptic localization of TRKB and its activation by BDNF. Extensive computational approaches including atomistic molecular dynamics simulations revealed a binding site at the transmembrane region of TRKB dimers. Mutation of the TRKB antidepressant-binding motif impaired cellular, behavioral, and plasticity-promoting responses to antidepressants in vitro and in vivo. We suggest that binding to TRKB and allosteric facilitation of BDNF signaling is the common mechanism for antidepressant action, which may explain why typical antidepressants act slowly and how molecular effects of antidepressants are translated into clinical mood recovery.

Associations between statin use and suicidality, depression, anxiety, and seizures: a Swedish total-population cohort study

BACKGROUND

Statins have shown both protective and adverse associations with neuropsychiatric outcomes. We aimed to examine the possible associations between statins and suicidality, depression, anxiety, and seizures.

METHODS

Using Swedish national registers, we linked data on dispensed statin prescriptions with data on unplanned (emergency) hospital visits or specialised outpatient care for four neuropsychiatric outcomes: suicidal behaviour (including deaths from suicide), depressive disorders, anxiety disorders, and seizures. We included all individuals in the registries who were dispensed statins and who were aged 15 years or older between Jan 1, 2006, and Dec 31, 2013. We applied a within-individual design using stratified Cox proportional hazards regression to compare the incidence of the defined outcomes during periods on statins and periods off statins within each individual, thus adjusting for time-invariant confounders. Non-specific effects of treatment were tested by investigating these outcomes in relation to thiazide diuretic use and antihistamine use in the same cohort.

FINDINGS

The statin-users cohort comprised 1 149 384 individuals, of whom 1 015 949 (88·4%) were aged 50 years or older, 625 616 (54·4%) were male, and 523 768 (45·6%) were female. The study period consisted of 2 053 310 non-treatment periods and 2 997 545 treatment periods, and 957 216 (83·3%) individuals had a medication status change (from on statins to off statins, or vice versa). Suicide outcomes were found in 6372 (0·6%) individuals, depressive disorders in 23 745 (2·1%), anxiety disorders in 30 100 (2·6%), and seizures in 28 844 (2·5%). There were no clear associations between periods of statin treatment and suicidal behaviour or deaths from suicide (hazard ratio 0·99 [95% CI 0·90-1·08]), anxiety disorders (0·99 [0·95-1·02]), or seizures (1·00 [0·97-1·04]). Statins were associated with reduced hazards of depressive disorders (0·91 [0·87-0·94]), which remained after adjustment for concurrent antidepressant use (0·91 [0·88-0·94]). Hazard ratios for depressive disorders were 0·61 (0·38-1·00; n=14 718) with thiazide diuretic use and 0·84 (0·67-1·06; n=23 715) with antihistamine use.

INTERPRETATION

Statin use is not associated with suicidality, anxiety disorders, or seizures. Whether the observed association between statin use and reduced diagnoses of clinical depression is confounded by non-specific benefits related to being prescribed medication needs further research.

FUNDING

Wellcome Trust, Swedish Research Council, National Institute for Health Research (NIHR) Research Professorship, NIHR Oxford Health Biomedical Research Centre, American Foundation for Suicide Prevention, Karolinska Institutet.

The effect of combined treatment with SSRIs and renin-angiotensin system (RAS) drugs: A propensity score matched cohort study

Drugs acting on the renin-angiotensin system (RAS) may have beneficial effects on mental health. We investigated whether use of drugs acting on the RAS, as add-on to selective serotonin reuptake inhibitors (SSRIs), was associated with a reduced risk of psychiatric hospital contacts. We identified all individuals initiating treatment with an SSRI between 1997 and 2012. Individuals using an SSRI without concomitant use of a RAS drug (SSRI-only users) were propensity score matched 1:1 to individuals using both an SSRI and a drug acting on the RAS (SSRI+RAS users). The SSRI-only and SSRI+RAS users were followed for up to three years or until December 31, 2013. We performed Cox proportional hazard regression analyses to calculate risks for psychiatric hospital contacts, hospital contacts due to depression, suicidal behavior, and all-cause mortality. We followed 30,311 SSRI-only users and 30,311 SSRI+RAS users for a total of 49,327 person-years. Compared to SSRI-only users, concomitant use of SSRI+RAS was associated with a significantly reduced risk for psychiatric hospital contacts (hazard rate ratio (HRR)=0.91; 95%-confidence intervals (95%-CI)=0.84-0.98) and lower mortality rate (HRR=0.70; 95%-CI=0.66-0.75). The associations between SSRI+RAS use and psychiatric hospital contacts for depression (HRR=0.92; 95%-CI=0.80-1.05) and suicidal behavior (HRR=1.06; 95%-CI=0.79-1.42) were not statistically significant. In this observational cohort study, concomitant use of an SSRI and a drug acting on the RAS was associated with a slightly reduced risk for psychiatric hospital contacts, when compared to use of an SSRI alone.

Association Between Statin Use and Depressive Symptoms in a Large Community-Dwelling Older Population Living in Australia and the USA: A Cross-Sectional Study

BACKGROUND

Statin use has been frequently associated with depressive symptoms in an older population. However, the nature of this association is uncertain in the literature. In this study, we aimed to investigate the association of statin intake and the prevalence of depressive symptoms in healthy community-dwelling older adults living in Australia and the USA.

METHODS

We analysed baseline data from 19,114 participants, over 70 years of age (over 65 years of age, if from an ethnic minority). The association of self-reported statin use and prevalence of depressive symptoms, as measured by a validated depression scale [Center for Epidemiological Studies Depression Scale (CES-D 10)], was determined using logistic regression models. Multivariable logistic models were implemented to account for important demographics and other lifestyle and socioeconomic factors, such as sex, age, living status, education and smoking history.

RESULTS

A total of 5987 individuals were statin users. Of those, 633 (10.6%) had depressive symptoms (CES-D 10 cut-off ≥ 8), compared with 1246 (9.5%) of the non-statin users. In the unadjusted model, statin use was associated with an increase in prevalence of depressive symptoms (odds ratio 1.13, confidence interval 1.02-1.25, p = 0.02). However, after adjusting for important demographic and socioeconomic factors, the use of statins was not significantly associated with depressive symptoms (odds ratio 1.09, confidence interval 0.98-1.20, p = 0.11). In secondary analyses, only simvastatin was marginally associated with an increased prevalence of depressive symptoms. Statins were associated with a decreased prevalence of depressive symptoms in individuals with severe obesity (body mass index > 35 kg/m2) and an increased prevalence in participants between 75 and 84 years of age.

CONCLUSION

This study in a large community-dwelling older population did not show any association of statins with late-life depressive symptoms, after accounting for important socioeconomic and demographic factors. Confounding by indication is an important issue to be addressed in future pharmacoepidemiologic studies of statins.