Association between total serum cholesterol and depression,aggression, and suicidal ideations in war veterans with posttraumatic stress disorder: a cross-sectional study

Aim

To investigate the relationship between total serum cholesterol and levels of depression, aggression, and suicidal ideations in war veterans with posttraumatic stress disorder (PTSD) without psychiatric comorbidity.

Methods

A total of 203 male PTSD outpatients were assessed for the presence of depression, aggression, and suicidality using the 17-item Hamilton Depression Rating Scale (HAM-D₁₇), Corrigan Agitated Behavior Scale (CABS), and Scale for Suicide Ideation (SSI), respectively, followed by plasma lipid parameters determination (total cholesterol, high density lipoprotein HDL]-cholesterol, low density lipoprotein LDL]-cholesterol, and triglycerides). PTSD severity was assessed using the Clinician-Administered PTSD Scale for DSM-IV, Current and Lifetime Diagnostic Version (CAPS-DX) and the Clinical Global Impressions of Severity Scale (CGI-S), before which Mini-International Neuropsychiatric Interview (MINI) was administered to exclude psychiatric comorbidity and premorbidity.

Results

After adjustments for PTSD severity, age, body mass index, marital status, educational level, employment status, use of particular antidepressants, and other lipid parameters (LDL- and HDL- cholesterol and triglycerides), higher total cholesterol was significantly associated with lower odds for having higher suicidal ideation (SSI≥20) (odds ratio OR] 0.09; 95% confidence interval CI] 0.03-0.23], clinically significant aggression (CABS≥22) (OR 0.28; 95% CI 0.14-0.59), and at least moderate depressive symptoms (HAM-D₁₇≥17) (OR 0.20; 95% CI 0.08-0.48). Association of total cholesterol and HAM-D₁₇ scores was significantly moderated by the severity of PTSD symptoms (P < 0.001).

Conclusion

Our results indicate that higher total serum cholesterol is associated with lower scores on HAM-D₁₇, CABS, and SSI in patients with chronic PTSD.Posttraumatic stress disorder (PTSD) is one of the few mental disorders with a clearly identifiable cause. It is an anxiety disorder caused by exposure to a traumatic event that presented a threat to the physical integrity of persons themselves or other people in their surroundings (1). Key neurochemical PTSD features include altered catecholamines regulation, alterations in serotonergic system, and alterations in systems of aminoacids, peptides, and opioid neurotransmitters (2).Associations between serum lipids and various psychiatric disorders and some behavioral aspects (like aggressive behavior) and/or suicidality have been widely explored. Lower total cholesterol levels were predominantly found in patients with major depressive disorder (MDD) (3-9). Significantly higher high-density lipoprotein cholesterol (HDL-cholesterol) levels were found in depressive patients than in controls (7). Some studies found significantly lower HDL-cholesterol levels (10) and a lower HDL-cholesterol/total cholesterol ratio (5) in patients with MDD than in controls.A negative correlation (11-13) between serum cholesterol level and aggressive behavior was also found, confirming the cholesterol-serotonergic hypothesis of aggression (14,15). Inadequate cholesterol intake could lead to decreased central serotonin activity, which is associated with an increased risk for impulsive-aggressive behavior (14-18). Depression (19-21) and aggression are well-known suicidality risk factors (15,22).The correlation between hypocholesterolemia, decreased central serotonin activity, increased depressive potential, and increased suicidality risk (23-27) was confirmed, implicating that hypocholesterolemia might be indirectly, ie, through decreased central serotonin activity and increased depression potential (20,25,28), associated with an increased suicidality risk (15,19-24,26,27). In patients with anxiety disorders other than PTSD, like panic disorder (PD), lower HDL-cholesterol and higher very low density lipoprotein cholesterol (VLDL-cholesterol) levels were found to be associated with higher suicide ideations/risk (29). Significantly lower serum total cholesterol and LDL cholesterol levels were found in suicidal patients with PD than in control subjects (30).Hypercholesterolemia was found to be associated with chronic, war-related PTSD (31-34). In a study from Bosnia and Herzegovina, not only hypercholesterolemia but also increased VLDL- and HDL-cholesterol levels were found in war veterans with PTSD in comparison with war veterans without psychiatric disorders (35). A Croatian study found no significant differences in the total serum cholesterol level, LDL-, and HDL-cholesterol between war veterans with PTSD, war veterans without PTSD, and healthy volunteers (36).The aim of this study was to investigate the relationship between serum cholesterol and levels of depression, aggression, and suicidal ideations in war veterans with PTSD free of other psychiatric premorbidity and comorbidity.