Relationship among low cholesterol levels, depressive symptoms, aggression, hostility, and cynicism Frances M. Sahebzamani, PhD, Rita F. D’Aoust, PhD, Debra Friedrich, DNP, Aryan N. Aiyer, MD, Steven E. Reis, MD, Kevin E. Kip, PhD * University of South Florida, College of Nursing, 12901 Bruce B. Downs Boulevard, MDN, Room 2010, Tampa, FL 33612–4476, USA (Drs Sahebzamani, D’Aoust, and Kip; and Ms. Friedrich); and Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA (Drs. Aiyer and Reis) KEYWORDS: Aggression; Cholesterol; Cynicism; Depression; Epidemiology; HMG-CoA reductase inhibitors; Hostility BACKGROUND: Treatment guidelines for lipids have become increasingly more aggressive. However, naturally low or therapeutically reduced cholesterol levels may be associated with adverse psychological health symptoms, including depression, aggression, and hostility. OBJECTIVE: To examine relationships between low total cholesterol (TC) and low-density lipopro- tein (LDL) cholesterol levels and measures of psychosocial status among middle-aged adults. METHODS: A total of 1995 subjects enrolled in the Heart Strategies Concentrating on Risk Evalu- ation study with data on TC, LDL cholesterol, and self-reported ratings of psychological health were evaluated. To quantify ratings of depression, aggression, cynicism, and hostility, psychological mea- sures included the Center for Epidemiologic Studies Depression Scale (CES-D) and Cook-Medley Hostility Inventory. RESULTS: Of 1995 participants, 25.1% were taking a lipid-lowering agent at baseline. Mean CES-D scores were similar between participants with low (,150 mg/dL) versus greater ($150 mg/dL) TC and low (,100 mg/dL) versus higher ($100 mg/dL) LDL cholesterol. However, among 22 participants with LDL cholesterol ,70 mg/dL, the prevalence of clinically significant depressive symptomatology (CES- D score $16) was 31.8% compared with 12.1% in the remaining cohort (P 5.005). In multivariable anal- ysis, low LDL cholesterol (,100 mg/dL) was associated with cynicism (partial r 520.14, P 5 .02) and hostility (partial r 520.18, P 5 .004), but only in the subgroup of white subjects currently taking lipid- lowering medications. Low LDL cholesterol (versus non-low) was associated with greater aggression scores but only among participants currently taking psychiatric medications (3.4 6 1.7 vs 2.8 6 1.5, P 5 .02). CONCLUSIONS: Our data indicate mixed evidence for independent relationships between low total and LDL cholesterol levels and impaired psychological health. Ó 2013 National Lipid Association. All rights reserved. During the past decade, the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) has endorsed national prevention and treatment guidelines for cardiovascular risk reduction through the aggressive lowering of total cholesterol (TC) and low- density lipoprotein (LDL) levels as a strategy to reduce the progression of cardiovascular disease (CVD), morbidity, and mortality. 1 These guidelines recommend an optimal TC level of ,200 mg/dL with targeted recommendations for LDL levels ,100 mg/dL for high-risk patients with an * Corresponding author. E-mail address: kkip@health.usf.edu Submitted July 9, 2012. Accepted for publication January 27, 2013. 1933-2874/$ - see front matter Ó 2013 National Lipid Association. All rights reserved. http://dx.doi.org/10.1016/j.jacl.2013.01.004 Journal of Clinical Lipidology (2013) 7, 208–216