**7.4 Medication**

In the general population there are many studies evaluating the impact of lipid lowering in primary and secondary prevention of coronary heart disease and stroke, but there are some concerns about its value in primary prevention, especially in vulnerable population (Vrecer et al, 2003).

Whether a low or lowered serum cholesterol level is associated with harm has been the subject of debate for a long time; ever since the unexpected finding of an increased risk of noncardiovascular mortality in early trials of lipid-lowering therapy. Subsequent research has generated conflicting evidence regarding the relation between cholesterol and violent behavior, mental illness , with positive studies imputing alterations in central serotoninergic activity as a potential underlying mechanism. A case-control study studied a cohort of 94441 individuals, 458 had newly diagnosed depression and 105 had a recorded diagnosis of suicide risk. Compared with matched control subjects, and even after adjustment for potential confounders, neither dyslipidemia nor its treatment was associated with an increase risk of depression. Similarly, no association was found between treatment and suicide risk. (Yang, 2003).

A 3-month study demonstrated that statins prescribed to patients with schizophrenia and severe dyslipidemia whilst taking antipsychotic medication led to a significant improvement in lipid profiles (Hanssens et, 2007). An earlier study with rosuvastatin proved effective in managing dyslipidemia in schizophrenic patients on antipsychotics. This study showed improvement in lipid profiles but not benefits in terms of high-density lipoprotein, waist measurement, BMI or glucose homeostasis (De Hert et al, 2006).

This last study supports the view that statins can be safely used in the short term to control abnormal lipids levels. However, there are no long-term data on its impact on either relapse or all-cause mortality, and again this is a priority for research.

The presence of metabolic syndrome is an indication for more aggressive lipid-lowering measures. Medications that raise HDL, nicotinic acid or fibrates, may be particularly beneficial in patients with metabolic syndrome, but they have not been as widely studied as medications that lower LDL-cholesterol in patients with mental illness.

The preferred initial management is still very much a lifestyle modification approach including exercise and diet.
