Is statin use safe in individuals with psychotic disorders?


Sir: Individuals with schizophrenia and other serious mental illnesses have a mortality rate at least 2 times as high as those without psychotic disorders, with the excess mortality largely attributed to higher rates of death from cardiovascular disease. Wider use of cholesterol-lowering drugs (statins) to reduce cardiovascular risk in this setting has been suggested. However, widespread use of statin drugs in individuals with psychotic disorders may raise some concerns. Accumulating evidence suggests a relation between low cholesterol and violence, aggression, and hostility, notwithstanding that the biological basis for attributing causality for behavioral disorders and hypocholesterolemia is not clear. Indeed, decreased cholesterol levels seem to indicate a population at risk for parasuicide or completed suicide, and follow-up studies have found that individuals with lower cholesterol levels have an increased risk of completing suicide. Moreover, the inheritance of defects leading to low cholesterol levels could predispose individuals to violent and suicidal behavior. Interestingly, among patients with schizoaffective disorders, suicidal individuals have been shown to have statistically significantly lower levels of cholesterol than nonsuicidal patients. Of note, to the best of our knowledge, there has been no randomized trial evaluating the safety and efficacy of statins in patients with psychotic disorders. On the other hand, randomized trials with statins have not shown a definite association between cholesterol-lowering treatment and non–illness-related mortality from suicides, accidents, and violence. However, statin trials are specifically designed to test drug efficacy, often with run-in phases. Investigators usually conduct the studies in groups of patients who have few comorbidities and are not using many concomitant medications. Furthermore, when side effects are measured, their seriousness and severity are not graded. Indeed, in real-world clinical practice, it has been suggested that severe anger and irritability may occur in some statin users. Finally, lifestyle advice, especially recommendation of physical activity, should be regarded as the cornerstone of cardiovascular disease prevention in patients with schizophrenia. However, statin-related muscular complaints (the most frequent statin-related side effects) might interfere with the implementation of exercise. These side effects are of particular concern in a population with psychotic disorders who frequently experience motivation and energy problems, symptoms that fundamentally reduce their capacity for regular physical activity. The almost total focus on lowering cholesterol through the use of drugs can distract attention from relatively simple lifestyle changes that can achieve greater reductions in risk of cardiovascular disease in patients with serious mental illnesses.

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@article{Mascitelli2008IsSU, title={Is statin use safe in individuals with psychotic disorders?}, author={Luca Mascitelli and Francesca Pezzetta and Mark R. Goldstein}, journal={The Journal of clinical psychiatry}, year={2008}, volume={69 9}, pages={1499} }