Statins Can Prevent Cardiovascular Risk in Patients with Mental Disorders
People with major mental disorders such as schizophrenia and bipolar disorder are at increased risk for medical symptoms including overweight, obesity, high cholesterol or triglycerides, diabetes, and the metabolic syndrome, all of which increase risk of cardiovascular disease (heart attack), cerebrovascular disease (or strokes), and other medical difficulties. In a 2013 review article in the journal Bipolar Disorders, researcher Chittaranjan Andrade discussed the use of statins to prevent cardiovascular events in people with major mental disorders.
Statins decrease lipids, and have significant benefits in decreasing cardiac events, but their use is low among psychiatric populations. Psychiatric patients often receive less cardiac care. It may be up to their psychiatrists to push for aggressive prevention of cardiac illnesses.
The most significant side effect of statins is the possibility that they can increase risk of diabetes. In a meta-analysis by Preiss et al., intensive dosing with statins increased the risk of diabetes but also lowered the risk of cardiovascular events. In a year, 1,000 patients would get two extra cases of diabetes but 6.5 fewer cases of cardiovascular events. For patients at high risk for heart attack or stroke, a cardiovascular event is more dangerous than diabetes, so it makes sense to treat these patients with statins. In patients at lower risk, there is some evidence that diabetes risk was a problem mostly in patients with other risk factors for diabetes, including metabolic syndrome, impaired fasting glucose levels, a body mass index of 30 kg/m2 or higher, or glycated haemoglobin A (1c) above 6%.
Most studies of statins are conducted on patients in middle age, but there is a rationale for treating even younger patients with statins. Patients with bipolar disorder develop cardiovascular disease more than a decade earlier than controls. There is some evidence that cholesterol deposits in arteries begin even before age 20, and are cumulative. The risk-benefit ratio for statin use improves with years of use, so starting it earlier may lead to better prevention. Long-term use may reduce the risk of Alzheimer’s disease and Parkinson’s disease and some cancers in addition to reducing heart attacks and strokes.
Despite the risk of diabetes, it is important to consider statin use in psychiatric patients, especially those who receive antipsychotic medications. Even though these patients are also at higher risk for diabetes, the benefits of statins in reducing cardiac risks may outweigh these risks. Andrade suggests that a conservative rule of thumb would be that psychiatric patients above age 40 with clinically significant elevation of LDL (“bad”) cholesterol should be prescribed statins if three months of diet and exercise changes do not result in improvement, and patients above age 50 should be prescribed statins if they have diabetes or meet at least two of the criteria for the metabolic syndrome, keeping in mind that age and male gender are risk factors for cardiovascular disease, so many patients will already have several risk factors for heart disease. African, Hispanic, and South Asian patients are more vulnerable to cardiovascular disease, so statins may be more strongly indicated among these patients.
Another rationale for the use of statins is the finding that they prevented future depressions in a general population, as reported by Julie Pasco et al. in Psychotherapy and Psychosomatics in 2010, and after a cardiac intervention, as reported by Leslie Stafford and Michael Berk in BMC Medicine in 2013.
