Innovations In Clinical Neuroscience

MAR-APR 2018

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

Issue link: https://innovationscns.epubxp.com/i/964320

Contents of this Issue

Navigation

Page 24 of 55

25 ICNS INNOVATIONS IN CLINICAL NEUROSCIENCE March-April 2018 • Volume 15 • Number 3–4 R E T R O S P E C T I V E S T U D Y associated with behavioral changes, including aggression, mood or personality changes, and violent or homicidal/suicidal ideation. These psychiatric adverse effects resolved upon drug discontinuation and recurred upon rechallenge, which suggests a causative relationship. The behavioral changes observed all had negative implications for marriages, careers, and/ or safety of self and others. As a potential confounder, it should be noted that some of the patients in this series had underlying psychiatric conditions, indicating that psychiatric illnesses might be worsened. 1 Sahebzamani et al 5 reported conflicting relationships between cholesterol levels (specifically LDL and total cholesterol) and self-reported ratings of depression, aggression, cynicism, and hostility. Reduced LDL (<100mg/dL) was associated with increased hostility in a subgroup of Caucasian patients receiving cholesterol-lowering therapy and significantly greater aggression scores in patients concomitantly prescribed psychiatric medication. However, after adjustment for factors that can influence aggressive behaviors, a low LDL was not independently associated with aggression. 5 Golomb et al 11 reported that post- menopausal women over 45 years of age, with lower levels of aggression at baseline, who were treated with either simvastatin 20mg or pravastatin 40mg exhibited significantly increased aggressive behaviors compared to those treated with placebo after the six-month trial period. Conversely, male patients 40 years of age or younger, with higher levels of aggression at baseline, showed decreased aggressive behaviors compared to those treated with placebo. However, this significance was only observed after the removal of three marked male outliers. Otherwise, statin use did not result in a significant change in aggression from baseline. 11 Recent studies examining the association between statin therapy and increased aggressive behavior have shown conflicting results, which has further complicated the possible relationship between cholesterol- lowering therapy and increased occurrence of loss of behavioral control. The cardiovascular benefits associated with statins are well- documented, and because patients with serious mental illness (SMI) experience a disproportionate degree of early mortality associated with cardiovascular complications when compared to their non-SMI peers, a relationship between their use and aggression might negatively influence how hypercholesterolemia and atherosclerotic cardiovascular disease (ASCVD) risk reduction is managed in this population. 12 Our study evaluates whether the use of statin therapy or low cholesterol levels increase the incidence of aggression and behavioral changes in a psychiatric inpatient population. OBJEC TIVES There were two hypotheses tested in this study. The primary hypothesis was to determine whether statin use increased the risk of aggression and agitation, while the second hypothesis was to determine if low serum cholesterol level increased the risk of aggression in adult psychiatric patients admitted for inpatient hospitalization at a state psychiatric facility. METHODS The study was approved by the Institutional Review Board of record for the facility (New York State Psychiatric Institute). A retrospective patient chart review of adult inpatients who were hospitalized at a state psychiatric center between January 1, 2011, and December 31, 2015, was conducted. For the first hypothesis, patient charts were evaluated for the receipt of statin therapy and the date statin therapy was initiated. For the second hypothesis, patient charts were evaluated for fasting lipid panels, specifically total cholesterol, within one year of starting statin therapy or within one year of admission. For both hypotheses, agitation and aggression were measured by the requirement of an emergent psychiatric intervention "code green" (CG) or the intervention of a restraint or seclusion (RS) within one year of starting statin therapy or within one year of admission. There were 114 patients on statin therapy who met all inclusion criteria for both hypotheses. Of the 144 patients who met all inclusion criteria and did not receive statin therapy during their admission, 114 patients were randomly selected to serve as matched controls. Analysis of variance (ANOVA) statistical analyses were conducted using the Statistical Package for Social Sciences version 23 (SPSS v23) to evaluate the risk of increased aggression relative to statin use or as a consequence of low serum total cholesterol levels. The level for statistical significance was selected at p<0.05 to minimize the risk of Type I error. To be included in the study for either hypothesis, patients had to be older than 18 years of age and be inpatients at the state psychiatric center any time between January 1, 2011, and December 31, 2015. Patients admitted prior to January 1, 2011, or those who had a Criminal Procedure Law (CPL) designation were excluded. For the first hypothesis, patients with unknown statin therapy status or those initiated on statin therapy for more than 30 days following admission were excluded. To be included in the study for the second hypothesis, patients were required to have had a lipid panel obtained during the first year of admission or within one year of starting statin therapy. RESULTS Charts of 754 patients were reviewed. ANOVA testing was used to evaluate whether an increased risk of aggression and loss of behavioral control was observed in patients receiving statin therapy or with low serum cholesterol levels. Cholesterol levels were categorized into low, low normal, normal, and high levels. Of the 96 patients with low TCL, 50 were on a statin and 46 were not. Of the 69 patients with low normal TCL, 32 were on a statin and 37 were not. Of the 42 patients with normal TCL, 18 were on a statin and 24 were not. And of the 22 patients with high TCL, 15 were on a statin and seven were not. A total of 228 patients were included in the analysis. Eleven patients who were receiving statin therapy required at least one CG (5%), while five patients who were receiving statin therapy required at least one RS (2%). Thirty- three patients who were not receiving statin therapy required at least one CG (15%), while 14 patients who were not receiving statin therapy required at least one RS (6%). The remaining 165 patients (72%) included in the analysis did not require an emergent psychiatric intervention (Figure 1). Of the 114 patients on statin therapy, 11 (9.6%) required a total of 57 CGs and five (4.4%) required 27 RSs within one year of starting statin therapy. Of the 114 patients not receiving statin therapy, 33 (28.9%) required a total of 64 CGs and 14 (12.3%) required 27 RSs during their first year of inpatient hospitalization. Using ANOVA, we found no statistically significant relationship between

Articles in this issue

Archives of this issue

view archives of Innovations In Clinical Neuroscience - MAR-APR 2018