For a short period of time I wasn't convinced I wanted to return to private practice, as I wasn't sure I could well manage that life/work balance that is challenged when managing your own business so I took a position with a chiropractor who had a fairly large primary care practice. He had difficulty retaining an NP so I thought my experience working independently and having run a successful practice would complement the needs of this role, particularly because we were both functionally-minded. True to any collaboration, we didn't always meet eye-to-eye on client scenarios and one of those was regarding cholesterol. He was happy with levels below 200 without further discussion, but I felt it was important to also evaluate the low end of that reading.
Our bodies require fat to function properly. Our brains are primarily fat, as are our cell membranes. I think of fats in our body like oil in farming machinery. Can you imagine not oiling your tractor for a few decades and continuing to run the equipment year after year? It would clearly get hot and stop working in time, just as our bodies get inflamed and become diseased. Our hormones as well require sufficient fat production, so prescribing #testosterone without first evaluating an appropriate fat level is rather short-sided.
Several times during my experience in this practice, I had discovered lipid levels nearing 100, some even quite lower. My alarm was not well-received by the owner of this practice. Here's my argument. Feel free to use if if your own clinician dismisses a low cholesterol finding.
By the end of the 1980s, the accumulated evidence for links between dietary fat, serum cholesterol, and cardiovascular disease was clear that elevated cholesterol levels should be reduced as a dietary intervention or even drug therapy, to protect cardiovascular health. Not long after however, a body of science presented the risk of cholesterol being too low.
Although high circulating cholesterol is unhealthy, cholesterol, which makes up 15 percent of the dry weight of the brain, is vital for proper brain functioning. Because it modifies cell brains, enzyme function, absorption and transport of fat-soluble vitamins, toxins and steroid hormones, and effects production, reuptake, and metabolism of neurotransmitters - it seems reckless to just work to lower the level without identifying those who may actually go too low, either from medication or potentially because of fat metabolism issues, such as poor gut health.
For the past thirty-five years, we have had research which linked low serum total #cholesterol to #suicide. Epidemiologically, it has been reported that violent suicidal attempts are found to have significantly lower cholesterol levels and higher cortisol levels attributed to probable depressive symptoms and malnutrition.
Low cholesterol and increased risk of suicide have also been reported in criminal violence, impulsive aggressive behavior, mood disorders, substance abuse, psychosis, and personality disorders. Violent suicide completers also show significantly lower cholesterol and platelet serotonin in the first episode of psychosis in comparison to nonviolent and healthy controls.
Why is this so?
Scientists aren't entirely sure, but there is theory that abnormality in leptin and lipid metabolism is linked to suicidal behavior. Postmortem brain studies have indicated that violent suicides were found to have lower gray-matter cholesterol content when compared to nonviolent suicides, specifically in the frontal cortex. Low serum cholesterol reflects reduced cholesterol content in the brain, specifically in brain cell membranes. This might impact the serotonergic system, due to the lowering of lipid microviscosity of the brain cell membranes. Reduced brain cholesterol might also affect synaptic plasticity, because cholesterol is required for synapse formation.
There is some evidence that lipid fluidity markedly modulates the binding of serotonin in the brains of mice, so theory is that with low cholesterol levels, the cellular membrane fluidity increases and serotonin receptors are less to serotonin in the synaptic cleft. There is also evidence between reduced serotonin and suicide, so this seems a valid theory. There are reports as well, that polyunsaturated fatty acid (PUFAs) may play a role in suicidality. People who eat fish frequently have far lower rates of suicide, as well as bipolar and postpartum depression.
If individuals have fat absorption issues, potentially they also have fat-soluble vitamin absorption issues which are ultimately playing a role in their mental health. Bile acids and carotenoids depend on the presence of fat, as do other fat-soluble vitamins which offer antioxidant properties. Oxidative damage occurs with reduced antioxidants and insufficiency of circulating serum vitamin/antioxidant has been linked with suicidal behavior. Low serum fats is likely to also be associated with vitamin D, which plays a plethora of roles in our wellness.
I find this significant. When I was working in my post-graduate program, somewhere along the way I read about these findings and soon after cared for a client in the clinic who was coming in from the local psychiatric center with a medical escort. His mental health struggles were profound, and his total cholesterol was 74. Just as my experience this past year, when I shared my concerns with the resident physicians and my own mentor, they shared no concern. In fact, they were completely unfamiliar with this relationship.
Certainly there are many other factors involved in psychopathology. This is not a homogeneous group and there is a huge variation in their phenomenology, neurobiology, neurochemistry, and risk factor profile. Social factors play a role and cognitive symptoms differ significantly.
Cholesterol has wide-ranging implications in neurobiology for the central nervous system. It plays a crucial role in neuronal protection, membrane stabilization, and lipid metabolism in neurons and as a part of the second messenger system. It has also been indirectly linked to norepinephrine and serotonin levels in the brain.
Suicide is an Important Problem
This is one of the leading causes of death, worldwide. Suicide can generate a wave of psychiatric events in affected families, and causes a great burden for society and hurt for others. There are a number of known causes, including mental disorders, aggression or impulsivity, family history of suicide, obesity, smoking, marital problems, work problems, and poor physical health.
A meta-analysis evaluating the association between various serum lipid levels and suicidality revealed that the serum total cholesterol and serum LDL levels were significantly lower in suicidal patients than in both non-suicidal patients and healthy controls, that the serum HDL level was significantly lower in suicidal patients than in healthy controls and that the serum triglyceride level was significantly lower in suicidal patients than in non-suicidal patients. As well, the same meta-analysis found a borderline significant 112 percent higher risk of suicidality for those in the lower serum total cholesterol level category than in those in the highest serum total cholesterol level category.
This meta-analysis further found that not only is low serum lipid levels an interesting predictive marker for suicidal acts, but it is also for suicidal ideation, suicide attempt and even suicidal tendencies. Further, an increasing number of reports raise the possibility that statins, a class of lipid-lowering agents, may be associated with deleterious cognitive, mood and behavioral adverse effects, including violence, depression and suicide, which have been attributed to the effect of statins' cholesterol level reduction on brain function. This seemed to be more significant in individuals younger than 40 years.
References
De Berardis, D., Serroni, N., Campanella, D., Marini, S., Rapini, G., Valchera, A., Iasevoli, F., Mazza, M., Fornaro, M., Perna, G., Di Iorio, G., Martinotti, G., & Di Giannantonio, M. (2017). Alexithymia, suicide ideation, c-reactive protein, and serum lipid levels among outpatients with genralized anxiety disorder. Archives of Suicide Research, 21 100-112.
Lalovic, A., Levy, E., Canetti, L., Sequeira, A., Montoudis, A., & Turecki, G. (2007). Fatty acid composition in postmortem brains of people who completed suicide. J Psychiatry Neurosci, 32(5), 363-70.
Messaoud, A., Mensi, R., Mrad, A., Mhalla, A., Azizi, I., Amemou, B., Trabelsi, I., Grissa, M. H., Haj Salem, N., Chadly, A., Douki, W., Najjar, M. F., & Gaha, L. (2017). Is low total cholesterol levels associated with suicide attempt in depressive patients? Ann Gen Psychiatry, 16:20.
Shrivastava, A., Johnston, M., Campbell, R., De Sousa, A., & Shah, N. (2018). Serum cholesterol and suicide in first episode psychosis: A preliminary study. Indian Journal of Psychiatry, 59, 478-82.
Wu, S., Sing, Y., Wu, F., XIe, G., Hou, J., & Mao, P. (2015). Serum lipid levels and suicidality: A meta-analysis of 65 epidemiological studies. J Psychiatry Neurosci, 41(1), 56-69.
Zhang, J. (2011). Epidemiological link between low cholesterol and suicidality: A puzzle never finished. Nutritional Neuroscience, 14(6), 268-287.
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