Cholesterol, mood, and vascular health: Untangling the relationship
Does low cholesterol predispose to depression and suicide, or vice versa?
Patients should receive a fasting lipid profile before and 12 weeks after starting any antipsychotic and semiannually thereafter.29 Consider closely monitoring lipids when patients gain weight with psychotropics. Refer patients with hyperlipidemia to a primary care physician, but in the absence of such a provider, mental health clinicians who are familiar with treatment guidelines can manage these patients.30
Closely monitor individuals with mood disorders for changes in behavior or mental status after starting a lipid-lowering agent. Consider discontinuing the drug if a patient develops an adverse reaction. If symptoms return after medication rechallenge, consider other management strategies such as an alternate lipid-lowering agent or re-emphasizing behavioral measures.
Table 2
National Cholesterol Education Program recommended LDL levels
| Risk category* | LDL goal | When to consider medications |
|---|---|---|
| CHD or CHD equivalent | <100 mg/dL | ≥130 mg/dL |
| ≥2 major risk factors | <130 mg/dL | ≥130 to 160 mg/dL (based on 10-year risk) |
| 0 or 1 risk factor | <160 mg/dL | ≥190 mg/dL |
| CHD: coronary heart disease; HDL: high-density lipoprotein; LDL: low-density lipoprotein | ||
| *Risk category is based on the presence of CHD or equivalent and major risk factors for CHD. CHD equivalents include symptomatic carotid artery disease, peripheral artery disease, and abdominal aortic aneurysm. Major risk factors include smoking, hypertension, low HDL, family history, and age. LDL levels to consider medications for those with ≥2 major risk factors vary by 10-year CHD risk | ||
| Source: National Cholesterol Education Program, Adult Treatment Panel III (ATP III) Quick Desk Reference. www.nhlbi.nih.gov/guidelines/cholesterol/atglance.htm | ||
National Cholesterol Education Program guidelines state that when a patient’s low-density lipoprotein cholesterol (LDL-C) exceeds targets (Table 2), first recommend lifestyle changes such as a diet low in saturated fat (<7% of calories) and cholesterol (<200 mg/d), weight management, and exercise. Increases in soluble fiber (10 to 25 g/d) and plant stanols/sterols also may be considered. If LDL-C levels are still too high, pharmacologic therapy such as an HMGCoA reductase inhibitor is suggested.
Treatment of elevated triglycerides (≥150 mg/dL) includes reaching the target LDL-C, intensifying a weight management program, and increasing exercise. Address quitting smoking and limiting alcohol when indicated. If triglyceride levels are ≥200 mg/dL after the LDL-C target is reached, set a secondary goal of reaching a target non-high-density lipoprotein cholesterol (HDL-C) (non-HDL-C; total cholesterol minus HDL-C) 30 mg/dL greater than the LDL goal. This can be achieved by adding an LDL-lowering drug such as a statin, nicotinic acid, or ezetimibe. When triglycerides are ≥500 mg/dL, more aggressive intervention, such as with a fibrate, omega-3 fatty acids, very low-fat diets, and exercise, is required to prevent pancreatitis.
Source: National Heart Lung and Blood Institute. National Cholesterol Education Program. www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
Related Resources
- Fiedorowicz JG, Coryell WH. Cholesterol and suicide attempts: a prospective study of depressed inpatients. Psychiatry Res. 2007;152(1):11-20.
- National Cholesterol Education Program, Adult Treatment Panel III (ATP III) Quick Desk Reference. www.nhlbi.nih.gov/guidelines/cholesterol/atglance.htm.
- Executive Summary of the third report of the national Cholesterol Education Program (nCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-2497.
Drug Brand Names
- Ezetimibe • Zetia
- Pravastatin • Pravachol
- Simvastatin • Zocor
Acknowledgements
Dr. Fiedorowicz thanks Lois Warren and Miriam Weiner for their editorial assistance.
Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Fiedorowicz is supported by the national Institutes of Health (1K23MH083695-01A210), nARSAD, and the Institute for Clinical and Translational Science at the University of Iowa (3 UL1 RR024979-03S4). He has received support for participating in a colleague’s investigator-initiated project with Eli Lilly. Dr. Haynes’ research is supported by grants from the national Institutes of Health (nHLBI: HL58972 & HL14388; nCRR CTSA: 1UL1RR024979).
